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.

2. Principles and national reporting for perinatal adverse event reviews

The HIS National Framework includes a number of overarching principles. For a robust and consistent maternity and neonatal review process in Scotland the National Framework principles have been further enhanced where required to apply in maternity and neonatal settings, and were co-produced with maternity and neonatal professionals and service users.

1. Openness and compassion: Women and families understand and are fully involved in the review and are enabled to ask the questions that they would like answers to. Staff treat families with compassion and kindness, are open and transparent in their communication and are themselves treated with compassion and kindness by their employer.

2. Teamwork: Review panels should be multidisciplinary and reflect all professions involved in the care. Review panels should have at least one member external (as per HIS Framework) to the team to enhance transparency and objectivity.

3. Review analysis: The review should be conducted using a systems and human factors-based methodology.

4. Training: Roles and responsibilities in a review are clear and understood and staff involved have received appropriate training and guidance on the review process.

5. Timescales: Review processes should be carried out in accordance with the guidance timescales in the National Framework.

6. Learning: from maternity and neonatal reviews should be captured and shared locally and nationally across the Scottish Perinatal Network.

7. Category 1 Event, Significant Adverse Event Reviews (SAERs) commissioned are to be reported to HIS via the agreed national notification system process[6] (see Appendix B).

8. Perinatal Mortality Review Tool (PMRT) should be used for all perinatal death reviews.

9. NHS Boards should comply with statutory reporting of perinatal deaths to the Procurator Fiscal.

10. Reviews should incorporate and comply with the statutory Duty of Candour.[7]



Back to top