Perinatal Mortality Review Report, November 2023
In 2023 we commissioned a piece of work to collectively review cases of stillbirth and neonatal loss at our hospitals between January 2020 and March 2023.
This is because, across that time, our data was showing that we were experiencing more stillbirth and neonatal losses than expected, and that we were an outlier against the national average.
Every baby loss is a tragedy and while some cases are, very sadly, unavoidable, we wanted to look collectively at the cases to make sure there were no themes we had not already identified, or additional changes we could put in place to improve care. Although every case was investigated individually at the time, we also wanted to look at the care we gave to the mother and baby again, as well as the processes we followed at the time.
The review highlighted some concerns, particularly around our compliance with national guidance and how we involved and supported families following a loss. It also highlighted cases where we could and should have done better, and areas where we had the opportunity to make care safer and improve the experience for families. We remain deeply sorry to the families who we let down at that time.
We accepted the recommendations and have acted on them.
The report found that 20 families had not been involved in the review process that we undertake when a baby sadly dies. After receiving the report, the Trust identified a further four families, giving a total of 24. This should not have happened, and we have proactively contacted those families to personally apologise and to answer any questions or concerns they might have.
Many of the wider themes in the review were similar to those highlighted in other reports from around the same period, including from the Care Quality Commission (CQC), and these now form part of our wider Maternity and Neonatal Improvement Programme >
We have made significant improvements to our maternity and neonatal services, and are providing safer care than we were 18 months ago, with better outcomes for mothers and babies.
Our compliance against national maternity safety standards has improved and we have invested in more staff, training and equipment and are involving families in the changes we are making.
While we have made progress, we are not complacent, and our teams remain focused on delivering safer, personalised and professional care to every family using our maternity services now and in the future.
If you have any concerns about this report or want to speak to us, please reach out. Please contact our Patient Advice and Liaison Service (PALS) >, or speak directly to our staff if you are already under our care.
Download UHDB Perinatal Mortality Thematic Review, Jan 2020 - Mar 2023 [pdf] 16MB
Please note: we have chosen to publish this report as part of our commitment to openness and transparency with local people; however small amounts of information in the report that could be considered personal or identifiable information has been redacted (removed) to protect the identities of those involved.
NHS England Maternity Services Diagnostic Report
We invited the NHSE Maternity Improvement team to do a review of our maternity services, to help support our improvement journey and key areas for focus.
The NHSE review was undertaken by a multi-disciplinary team in January 2023, and consisted of on-site visits at Royal Derby Hospital (RDH) and Queen's Hospital Burton (QHB).
Following the review, we were advised that we did not meet the criteria to be a part of a national intensive support programme, however we have asked that we receive support on an informal and voluntary basis from the national team to support our improvement journey.
The review provided a great deal of feedback and opportunities for learning, and progress on these findings is being monitored through our governance processes.
Download NHS England Maternity service review diagnostic report [pdf] 12MB (opens in new window) >
Maternity learning review, published February 2023
In February 2023 we published the report findings from an independent maternity learning review > we requested. The Trust - taking lessons from national reports that have highlighted the need for openness to learning from incidents - asked the NHS Derby and Derbyshire Integrated Care Board to commission an independent review into seven maternity incidents that took place at Royal Derby Hospital between January 2021 and May 2022.
The cases over this 16-month period sadly related to three maternal deaths and four maternal collapses; all seven cases had already been individually investigated, but allowing an independent team to review them collectively was designed to give the Trust and the families involved assurance that all possible learning had been identified.
Although the review did not find any common themes that impacted on the outcomes for all the women involved, there has been learning for us an organisation which we have taken very seriously, and the recommendations are invaluable in helping us further improve safety and the experience of women under our care.