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.

Appendix A: Perinatal mortality review tool

The PMRT tool will support:

  • systematic, multidisciplinary, high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death ensuring that the care of babies who die in the post-neonatal period in neonatal units can also be reviewed using the PMRT;
  • active communication with parents to ensure they are told that a review of their care and that of their baby will be carried out and how they can contribute to the process;
  • a structured process of review, learning, reporting and actions to improve future care;
  • coming to a clear understanding of why each baby died if possible, accepting that this may not always be possible even when full clinical investigations have been undertaken; (this will involve a grading of the care provided);
  • production of a report for parents of why their baby died and whether, with different actions, the death of their baby might have been prevented;
  • other reports from the tool which will enable organisations providing and commissioning care to identify emerging themes across a number of deaths to support learning and changes in the delivery of care to improve future care and prevent the future deaths which are avoidable;
  • production of national reports of the themes and trends associated with perinatal deaths to enable national lessons to be learned from the nationwide system of reviews.

PMRT Review Group

Core Group*

Roles within group:

  • Chair and Vice-Chair
  • Scribe/IT/Admin Support
  • PMRT Champion

Minimum of 2 of each of the following:

  • Obstetrician
  • Midwife
  • Neonatologist and Neonatal Nurse
    • All cases where resuscitation was commenced
    • All neonatal deaths
  • Risk manager/governance team member (1 acceptable) e.g. service manager
  • Bereavement team (1 acceptable)
  • External panel member (1 acceptable)

* Group members can fulfil multiple roles

Additional Members

Named and invited to attend or contribute where applicable:

  • Pathologist – when a PM was performed
  • GP/Community Healthcare
  • Anaesthetist
  • Sonographer/Radiographer
  • Safeguarding team
  • Service manager
  • Any other relevant healthcare team members pertinent to case

All opinions and views are equal, facilitate a breadth of discussion



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