Around 1 in 5 deaths reviewed by hospitals in 2021 to 2022 were potentially avoidable according to the Perinatal Mortality Review Tool's 4th annual report. This means that safer, more personalised care, that followed guidelines and addressed the mother's or baby's needs might have saved the baby's life. NHS staff have a Duty of Candour to be open and honest with families when something goes wrong in NHS care. If there's any concern that the care you received did not meet national or local guidelines and this may have contributed to your baby’s death, an urgent Patient Safety Incident Investigation (PSII in England, Wales or N. Ireland) or a Significant Adverse Event Review (SAER in Scotland) will be carried out.

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What is a patient safety incident investigation?

Both the PSII and SAER look at the circumstances that led to your baby's death to identify what went wrong with NHS care. A PSII is carried out by the maternity service where you received your care. A PSII and SAER are the highest level of investigation a Trust or Health Board can undertake to understand if a family received poor care and the death of their baby was potentially avoidable.

What does it involve?

The findings of the PSII and SAER will be used to complete the hospital review (PMRT). PSII and SAERs have a lead investigator who is from the maternity or neonatal service. A multidisciplinary team will review your and your baby’s medical notes. This team must include an external specialist who is from a different hospital but has knowledge in a field relevant to your case. This provides some oversight to ensure the service is critical of its own performance and procedures. The final report should contain actions the service must take to prevent the same thing from happening again. 

How will I find out the results of the investigation?

Ideally, the PSII and SAER report should be shared with you while it is still in draft form so you can look at it and comment on it, before it is finalised. It can take many weeks or months for a full PSII to be completed. Your key contact should let you know when you can see the draft report. 

Once the report is finalised, you should be asked if you would like to hear about its findings in a face to face meeting with a senior clinician. If you have questions they should be answered. 

The maternity service must be open and honest with you about any mistakes they may have made. This is called the duty of candour. Conducting robust investigations and being open and honest about mistakes ensures that the service learns from poor care to prevent future harm or deaths.

What are my options if I am not happy with the investigation or the report findings? 

If the hospital review has not answered your questions you have the right to raise a complaint or concern. This right is protected by the NHS constitution. But it isn’t always clear how to do this. The complaints and feedback section might help answer your questions about how, and to whom you should complain.

How can I find out more about Duty of Candour?

Action Against Medical Accidents or AvMA has provided information for patients around Duty of Candour you may find helpful.