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  • Led by North Bristol NHS Trust, in partnership with the University of Bristol, the International Stillbirth Alliance and the University of Manchester.
  • Aimed to improve the review process after the death of a baby in hospital, to help parents deal with their grief more effectively and drive improvements in patient safety.
  • Involved incorporating input from parents into the hospital review process in two UK hospitals.

The Safer Maternity Care campaign has pledged to reduce the number of perinatal deaths by half by 2025, by improving reviews and lessons learned after a baby has died.

In 2015 there were 4,583 stillbirths and neonatal deaths at age under seven days (perinatal mortality) in the UK. The perinatal mortality review meeting (PNMR) that takes place within the hospital enables clinicians to learn vital lessons to improve care in the future. However, evidence suggests that parents are unaware that a formal review takes place following the death of their baby, and many would welcome the opportunity to provide feedback. 

Parental involvement in the PNMR could improve patient satisfaction, drive improvements in patient safety, and promote an open culture within health care. 

This project involved parents in the PNMR process at two hospitals in North Bristol and Central Manchester University Hospitals NHS Trusts. Challenges included obtaining buy-in from health care professionals, as there were initial concerns and fears about the number of complaints that might be received. However, the initiative was developed using input from bereaved parents, stakeholders, charities and health care professionals. 

The project has already had an impact through better patient experience, improvements in hospital processes and increases in patient safety.

There has been a request to apply the project’s findings to serious untoward incidents and patient safety incidents at North Bristol NHS Trust. The findings have informed the National Perinatal Mortality Review Tool, which will be rolled out across the UK in 2018; the Department of Health’s Bereavement Care Pathway; and the revised international Royal College of Obstetricians and Gynaecologists’ management of stillbirth guidance.

Contact information

For more information about this project, please contact Dr Christy Burden, National Institute for Health Research Academic Clinical Lecturer, Obstetrics and Gynaecology, Southmead Hospital, Bristol.

About this programme

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