Improve perinatal mortality recording

103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has established a system to systematically collect and report surveillance information on all stillbirths and neonatal deaths nationally. MBRRACE-UK published its first Perinatal Mortality Surveillance Report on the 10th June 2015. It provides crude and also stabilised and adjusted neonatal mortality rates in 2013 by service delivery organisation (operational delivery network in England), by place of birth, and by commissioning area (Clinical Commissioning Group in England). In autumn they will provide Trusts with individual Trust-level reports to enable them to more closely scrutinise their own rates in comparison with Trusts providing similar types of care (for high versus low risk women) and to better understand where deaths occur to babies born in the Trust and those who die having transferred into the Trust for higher level neonatal care. 105. Any Care Quality Commission maternity outlier is alerted to Trusts where there is a cause for concern. In addition the Care Quality Commission and MBRRACE are establishing pursuing a data-sharing agreement which would allow inspectors to receive a regular update of all maternal deaths.

The Thirlwall Inquiry has noted action taken in response to this recommendation.

All stillbirths and neonatal deaths must be reported to MBRRACE-UK within 30 days. MBRRACE-UK validate their data against ONS data. Rates of stillbirth, neonatal death, and extended perinatal death are reported for NHS Trusts in England based on place of birth. For a significant number of deaths some of the data required will be held in more than one hospital, e.g. some aspects of maternal data after the death of a baby following postnatal transfer. If the additional information is held within the same Trust or Health Board but on a different site then reporters can access all the information they need in collaboration with obstetric, midwifery, neonatal or nursing colleagues. However, if the missing information is held by a different Trust or Health Board, then the MBRRACE-UK system allows the reporter to temporarily assign ownership of the MBRRACE-UK record to the other Trust or Health Board who can then return it once the missing information has been provided. A Perinatal Mortality Review Tool was launched in January 2018 and has now been implemented in 100% of English Trusts. The tool aims to promote: systematic, multidisciplinary, high quality reviews of the circumstances and care leading up the death of the baby; active communication with parents and an invitation to be actively involved in the review process; a structured process of review, learning, reporting and actions to improve future care.

The National Maternity Indicator dashboard enables clinical teams in maternity services to compare their performance with their peers on a series of Clinical Quality Improvement Metrics (CQIMs) and National Maternity Indicators (NMIs), for the purposes of identifying areas that may require local clinical quality improvement.

NMIs are annually published indicators drawn from external data sources such as the National Maternity and Perinatal Audit, MBRRACE-UK, CQC Maternity Survey, NHS Staff Survey, and the GMC Survey. These indicators have been selected to provide a holistic picture of the performance of maternity services and cover five different domains including mortality and morbidity. They allow for comparison with other units but given mortality data is based on MBBRACE-UK there is an associated time lag.

The National Neonatal Audit Programme (NNAP) is a national clinical audit run by the Royal College of Paediatrics and Child Health (RCPCH) on behalf of the NHS. It is commissioned by the Healthcare Quality Improvement Partnership (HQIP). It aims to helps neonatal units improve care for babies and their families by identifying areas for quality improvement in relation to the delivery and outcomes of care.

NNAP produces an interactive data dashboard showing data on 10 performance metrics, including mortality, and is updated on a quarterly basis.

A Perinatal Mortality Review Tool was launched in January 2018 and has now been implemented in 100% of English trusts.

The Government has introduced measures to improve the systematic recording of perinatal deaths.

The Perinatal Mortality Review Tool was launched in 2018 to support National Health Service trusts to undertake systematic, multidisciplinary, high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death. Reports from the tool enable organisations providing and commissioning care to identify emerging themes across a number of deaths to support learning and changes in the delivery and commissioning of care to improve future care and prevent the future deaths which are avoidable.

In May 2019, MBRRACE-UK introduced a new real-time data monitoring tool, incorporated into the MBRRACE-UK web-based system. The tool allows registered users of the MBRRACE-UK surveillance system to monitor, filter and summarise the perinatal deaths reported for their organisation, using live surveillance data from the MBRRACE-UK system.

Department of Health response (July 2015): Accepted. “MBRRACE-UK has established a system to systematically collect and report surveillance information on all stillbirths and neonatal deaths nationally. MBRRACE-UK published its first Perinatal Mortality Surveillance Report on the 10th June 2015 (for 2013). […] Any Care Quality Commission maternity outlier is alerted to Trusts where there is a cause for concern. In addition the Care Quality Commission and MBRRACE are establishing pursuing a data-sharing agreement which would allow inspectors to receive a regular update of all maternal deaths” (p. 93)