The Royal College of Midwives (RCM) has called for action to address ongoing issues in maternity care highlighted by the latest National Perinatal Mortality Review Tool (PMRT) annual report, published today (Thursday 9 October).
The report, which reviewed 4,166 cases of perinatal death across the UK between January and December 2024, shows encouraging progress in the quality of reviews and greater involvement of parents. However, it also reveals that the vast majority of reviews – 94% – identified at least one issue with care.
Rachel Drain, Quality and Standards Advisor at the RCM, said:
“Every baby’s death is a tragedy and we owe it to those families to learn from every single one. This report shows welcome improvements in the quality of reviews and in involving parents in the process, but it is deeply concerning that most reviews still identify problems in care.
“Midwives and maternity teams are working tirelessly under significant pressure and they can only deliver the safest possible care if services are properly resourced and staffed. The findings in this report must drive urgent action – from government, NHS trusts and health boards – to ensure midwives have the time, training and support they need to provide the high-quality, compassionate care that every woman, baby and family deserves.
“We also support the call for improved parent engagement, ensuring staff are trained and supported to involve families meaningfully and sensitively at every stage of review.”
The RCM welcomes recommendations from the report, including calls to strengthen parent engagement and ensure adequate staffing and resources for review meetings. The RCM said these steps are vital to embed learning and drive system-level improvements across maternity services. The College is also calling for investment into interpreting services, to ensure women and families have reliable access when needed.
The report found that:
- While nearly all parents (99%) were told about the review of their baby’s death, and 98% were asked if they had any questions, the report found that many parents were not always clear on what the process involved.
- More than one in five (22%) said they had concerns about the care they received, and 12% raised issues about staff approach and how their care was delivered.
- 36% of reviews identified problems during labour or birth that may have affected the outcome for the mother or baby, with issues such as inadequate monitoring, staffing pressures and communication barriers remaining consistent since 2020.
