The Perinatal Mortality Review Tool: What is it, when is it used and what can it tell us about the death of a newborn?

The Perinatal Mortality Review Tool (“PMRT”) is a standardised review tool used by medical and health professionals to review the quality of care given surrounding perinatal deaths, with the aim of identifying improvements in care to avoid future deaths.

The tool is used to review cases of late miscarriages, stillbirths and neonatal deaths occurring from 22 weeks’ gestation through to 28 days post-birth.

It was introduced in 2017 after a 2015 enquiry found that up to 60% of stillbirths might have been preventable with adherence to national or local guidelines. Additionally, it was found that only one in ten hospitals reviewed cases of perinatal deaths.

The charity SANDS was heavily involved in the development of the tool, which is run in a collaboration with MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK) amongst others, including the RCOG.

The tool allows for high quality multidisciplinary reviews of the circumstances and care leading up to and surrounding each perinatal death.

To identify contributing factors (originating from the NHS National Patient Safety Agency) towards the death, the tool looks at the following:

1. Patient factors: clinical condition, physical factors, social factors, psychological and mental factors, and interpersonal relationships;
2. Education and training factors: competence, supervision, availability and accessibility, and appropriateness;
3. Individual (staff) factors: physical factors, psychological factors, social and domestic factors, personality, and cognitive factors;
4. Equipment and resources: displays, integrity, positioning, and usability;
5. Task factors: guidelines, procedures, protocols, decision aids, and task design;
6. Working condition factors: administrative, physical environment design, staffing levels, workload and hours, and time of day;
7. Communication factors: verbal, written, non-verbal, and management;
8. Organisational and strategic factors: organisational structure, priorities, externally imported risks, and safety culture; and
9. Team factors: role congruence, leadership, support, and cultural factors.

It requires in-depth analysis of the standard care expected at a given medical practice, and whether that standard was met in each case of perinatal death. Even where the standard has been met, the tool scrutinises the adequacy of the standard itself.

If a post mortem examination has been undertaken then the outcome and post mortem report will be required in order for the PMRT report to be finalised. Usually the results of the post mortem are integrated into the PMRT report. Paediatric post mortems are only undertaken by specialist pathologists and they can take a very long time to be returned; this causes delays in finalising other reports by PMRT and MNSI (Maternity and Newborn Safety Investigations) and listing inquests.

As opposed to pinning blame, the tool seeks to find ways to make improvements in respect of each of the contributing factors towards the perinatal death, for example:

• If the death may have been avoided with access to an appropriate resource, the solution might be to ensure that resourcing is reviewed as a priority;
• Perhaps the death was caused by a lack of staff training regarding a piece of equipment. The solution could be to contact the provider of the equipment to request further training or to advise further emergency obstetric training to alleviate any systemic issues.

The review requires that a technical clinical report is produced for inclusion in the medical notes regarding the death. The report will “Grade” the level of care as follows:

• Grade A: The care provided was appropriate;
• Grade B: Care was generally appropriate, but with some minor issues that did not affect the outcome;
• Grade C: Care issues were identified that may have made a difference to the outcome;
• Grade D: Care issues identified that were likely to have made a difference to the outcome.

The tool allows for open communication with parents and where English is not a first language, translation services should be made available. Parents are informed that the review will be carried out, and additionally, how they can contribute to the review process. Once the review has been carried out, staff are expected to write a plain-language letter to the parents, naming their baby, including:

• an explanation as to why their baby died;
• an explanation as to whether, with different actions, the death of their baby might have been prevented; and
• responses to any questions they may have had about their care and that of their baby.

The tool also generates summary reports for trusts and health boards, identifying emerging themes across multiple cases. These add weight to necessary systematic changes locally.

In addition, national annual reports further analyse themes and trends in perinatal deaths, enabling lessons to be learned across the nation.

The PMRT report will be shared with MNSI investigators should that investigation be ongoing. The MNSI would not normally delay production of their report if a PMRT report is awaited and, as they are entirely separate processes, one does not depend on the other to be finalised.

It is usually helpful for MNSI staff to have the report in order to be better informed of internal conclusions reached by the Trust.

It is important to note that it is the Trust where the death occurred who undertake the PMRT review and prepare the report. Therefore, failures may have occurred at a different Trust to the one who prepares the report; this often happens when newborn babies are transferred to specialist intensive care (NICU units) in a different hospital.

If an inquest hearing is listed by a Coroner then they will usually seek to have sight of the PMRT report before the inquest is heard and may call the lead author of the report to comment upon their findings at the inquest hearing itself.

If you have questions or concerns raised by this article, get in touch with our birth injury or inquest team. Find out more through the links below.