Publication - Advice and guidance

Maternity and neonatal (perinatal) adverse event review process: guidance

Published: 15 Sep 2021
Directorate:
Children and Families Directorate
Part of:
Children and families
ISBN:
9781802013054

Operational guidance to support health boards boards undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services.

Maternity and neonatal (perinatal) adverse event review process: guidance
References

References

1. Learning from adverse events through reporting and review-A National Framework for Scotland: December 2019 Healthcare Improvement Scotland (healthcareimprovementscotland.org)

2. Perinatal Mortality Review Tool | NPEU (npeu.ox.ac.uk)

3. MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK | NPEU (npeu.ox.ac.uk)

4. Royal College of Obstetricians and Gynaecologists (2015) Each Baby Counts Summary Report 2015 (rcog.org.uk)

5. Healthcare Improvement Scotland Review of Ayrshire Maternity Unit, University Hospital Crosshouse, NHS Ayrshire & Arran (Adverse Events) June 2017 (healthcareimprovementscotland.org)

6. Healthcare Improvement Scotland (2018) Adverse Events: guidance on notifications data (healthcareimprovementscotland.org)

7. Scottish government (2018) Organisational duty of candour: guidance Organisational duty of candour: guidance - gov.scot (www.gov.scot)

8. MBRRACE-UK - Mothers and babies: Reducing Risk through Audits and Confidential Enquiries across the UK – MBRRACE-UK Perinatal Mortality Surveillance Report UK Perinatal Deaths for Births from January to December 2015 (npeu.ox.ac.uk)

9. National Patient Safety Agency (2009) National Reporting and Learning Service. Saying sorry when things go wrong - Being Open – communicating patient safety incidents with patients their families and carers.

10. Guijarro PM, Andres MA, Mira JJ, Perdiguero E, Aibar C Adverse events in hospital: the patient’s point of view BMJ Quality & Safety (2010;) 19:144-147

11. Redshaw M, Rowe R, Henderson, J (2014) Listening to parents after stillbirth or the death of their baby after birth National Perinatal Epidemiology Unit, University of Oxford

12. Healthcare Improvement Scotland (2015) Being Open in NHSScotland-Guidance on Implementing the Being Open principles (healthcareimprovementscotland.org)

13. Ockenden, D (2020) Maternity Services at Shrewsbury and Telford Trust. Ockenden Report - Maternity Services at the Shrewsbury and Telford Hospital NHS Trust (donnaockenden.com)

14. Kirkup, B (2015) The Report of the Morecambe Bay investigation

15 ‘Effective Communication about Adverse Events in Maternity Units - A guide to talking with parents, families and staff’

16. NPEU (2020) Parent engagement material Parent Engagement Materials | NPEU (ox.ac.uk)

17. NHS Education for Scotland (2020) Patient Safety Training | Turas | Learn (learn.nes.nhs.scot)

18. NHS Education for Scotland (2021) Why things go wrong or right in complex systems Aims and learning outcomes for “Why things go wrong...” | Turas | Learn (nhs.scot)

19. NHS Education for Scotland (2020) Interactive elearning module on Enhanced Significant Event Analysis (learn.nes.nhs.scot)

20. Crown Prosecution Service (2015) Reporting Deaths to the Procurator Fiscal Reporting Deaths to the Procurator Fiscal (copfs.gov.uk)


Contact

Email: thebeststart@gov.scot