Perinatal Mortality Review explained to better support bereaved parents | Fieldfisher
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Perinatal Mortality Review explained to better support bereaved parents

Caron Heyes

When a baby dies before, during or after birth, the hospital (or hospitals) that cared for the mother and baby should review the treatment using a National Perinatal Mortality Review Tool (PMRT).

This 'perinatal' or 'neonatal' review involves the clinical team studying the mother's and baby's hospital notes to understand the events leading up to the baby's death. It is there to provide as much information as possible to the parents and to create learning for improved care for the hospital trust. It will investigate what happened at every stage of the pregnancy and birth from initial booking in, to bereavement care and support when the family leaves hospital.

It is different to a coroner's investigation or inquest, a Maternity and Newborn Safety Investigation (MNSI) or a hospital's internal investigation. In England, some baby deaths are reviewed by the MNSI, in which case the hospital review is postponed until the MNSI investigation is complete.

The hospital should inform bereaved parents that the Perinatal mortality review will take place and should offer them the opportunity to ask questions and provide additional information. Parents will not be asked to attend the review meeting but should be offered an appointment to see the consultant to discuss the findings post review.

Post-mortem results should be considered within the review and discussed at the consultant appointment. This may be several weeks and might involve more than one appointment. The panel will summarise the review findings and produce a report for the parents to answer their questions and recommend actions to improve care.

Why review of care is important when a baby dies

Reviewing the death of every baby in a standardised, high-quality way is important to understand what happened and to provide parents with answers. It's also an important way to improve the health service to ensure every family receives the best care in the future. 

We hear again and again of failings in our maternity services, of avoidable deaths, birth trauma and babies and mothers suffering terrible injuries as a result. This tool can contribute to improving the quality of care by recognising trends, and what works well and what works badly.

The PMRT is an online tool, but the information it collects is not public. It is held securely at the University of Oxford as part of the wider maternity data programme, the MBRRACE-UK data system. This data system collects brief information about every pregnancy and birth that ends in late miscarriage, stillbirth or death of a baby to monitor what is happening in different hospitals, regions and countries in the UK and to understand what factors contribute to baby deaths so that MBRRACE-UK can make recommendations to prevent future deaths.

Read more about MBRRACE-UK data on maternal issues, stillbirths and baby deaths.

The Perinatal Mortality Review collects more information about individual mothers and babies than the MBRRACE-UK data system, because the hospital reviewers look in more detail at the care the mother and baby received throughout pregnancy, birth and afterwards.

Work is ongoing to make this tool work for parents, to improve parent engagement and to prevent future baby loss. Its work is linked to other key initiatives. Parents suffering baby loss should ask their hospital when the review panel will meet and when they can review the panel report.

Access more materials on the PMR here For any questions about the PMR process, how it works with other investigations and how it should support you, contact Caron Heyes on 03304606743 or email

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