Improve perinatal mortality recording
Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: NHS England
Source — verbatim from the inquiry
●Inquiry recommendation
Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units rely inappropriately on headline mortality figures to reassure others that all is well. We recommend that recording systems are reviewed and plans brought forward to improve systematic recording and tracking of perinatal deaths. This should build on the work of national audits such as MBRRACE-UK, and include the provision of comparative information to Trusts. Action: NHS England.
Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- MBRRACE-UK published its first Perinatal Mortality Surveillance Report on 10 June 2015, providing mortality rates by service delivery organisation and commissioning area (Learning Not Blaming, Cm 9113, Department of Health, July 2015).
- MBRRACE-UK publishes annual perinatal mortality surveillance reports with trust-level comparative data (MBRRACE-UK).
- The Perinatal Mortality Review Tool (PMRT), developed by MBRRACE-UK and launched nationally in 2018, provides a standardised process for reviewing perinatal deaths at trust level (NHS England).
Sources
Response — verbatim from government
●NHS England
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.
NHS England · 16 Jul 2015 Written response →
Evidence trail — what's actually happened since
- 31 Dec 2015 MBRRACE-UK programme strengthened. National reporting of perinatal mortality improved with comparative data for trusts. Source →
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
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Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
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