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

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


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

2. Perinatal Mortality Review Tool | NPEU (

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

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

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

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

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

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 (

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 (

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

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 (

17. NHS Education for Scotland (2020) Patient Safety Training | Turas | Learn (

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 (

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

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



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