38 Response Accepted AI-assessed

Improve perinatal mortality recording

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.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
According to NHS England's 2015 statement, this recommendation was accepted and the MBRRACE-UK programme was strengthened to systematically collect and report surveillance information on all stillbirths and neonatal deaths nationally. MBRRACE-UK published its first Perinatal Mortality Surveillance Report on 10 June 2015, providing comparative data for trusts.
How was this assessed?
Assessed by gemini-2.5-flash on 19 Mar 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.legislation.gov.uk, hansard.parliament.uk
This recommendation requires implementation across many organisations. The assessment reflects central policy response, not adoption in individual organisations.
Jurisdiction
England
Response
Accepted
Accepted NHS England
16 Jul 2015

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.

Read Full Response
Source
Inquiry Morecambe Bay Investigation
Report Report of the Morecambe Bay Investigation 03 Mar 2015
View Source
Responsible Bodies
NHS England Primary
Themes & Tags
Flawed mortality reviews Inaccurate and inaccessible patient records Palliative care data gaps Perinatal Mortality Recording Mbrrace-Uk
Recommendation age 11.1 yrs
Last formal update 3904 days ago