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.


In 2017 the Scottish Stillbirth Group conducted a survey of all health board processes. The review identified inconsistencies in terminology, definitions and methodology in perinatal service review processes across Scotland and this showed that the majority of stillbirths did not then undergo a Significant Adverse Event Review (SAER). It also highlighted different approaches to the involvement of families in reviews. Development of a consistent and standardised approach will support the ability to identify, to capture and to share learning and to provide a clear and robust explanation for women and families wherever they live in Scotland.

The survey also identified other areas of variable approaches across Health Boards, including:

  • the range of multidisciplinary staff attending reviews;
  • provision of training and protected staff time to participate in and to lead reviews;
  • inclusion of external input into reviews;
  • achieving local and national dissemination of learning and improvement from reviews.

In response to the recommendations from national audits, reports, and the Stillbirth Group review, the Scottish Government, alongside HIS and NES, has developed this standardised process for perinatal adverse event reviews and involving families and staff. This approach was tested in maternity services in two Health Boards and the process refined to incorporate the learning. Our thanks to NHS Lothian and NHS Ayrshire and Arran for leading the improvement work which contributed to this document.



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