Myth: External reviews into perinatal deaths are the answer

Many external inquiries into maternity services in Ireland have been carried out over the last 20 years, often after negative media reporting of adverse events in maternity hospitals, including baby deaths. However, inquiry recommendations have not been consistently or entirely implemented (47).

The approach to review of perinatal deaths is not uniform or transparent across maternity units (48). Bereaved parents do not feel their concerns and opinions are being taken into account and they want to contribute to the hospital’s review of their baby’s death (49).

A new, standardised, perinatal death review process and national confidential enquiry has been recommended by both the National Perinatal Epidemiology Centre (46) and the Health Service Executive National Standards for Bereavement Care (1). 

A standardised perinatal mortality review tool and review process may help strengthen perinatal death reviews, provide more information and opportunity for involvement for bereaved parents and help reduce future perinatal deaths, as evidenced in other countries (50–52).

References

(1) Health Service Executive. National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death. Version 2. Dublin: Health Service Executive; 2022. Available from: https://www.hse.ie/eng/services/list/3/maternity/bereavement-care/. 

(46) San Lazaro Campillo I, Manning E, Corcoran P, Keane J, McKernan J, Greene RA, et al. Perinatal Mortality National Clinical Audit in Ireland Annual  Report 2022. Cork: National Perinatal Epidemiology Centre; 2024. Available from: https://www.ucc.ie/en/media/training-2024/trainingacademia190/PerinatalMortalityFormReport2022-3526AW.pdf.

(47) Helps Ä, O’Donoghue K, O’Byrne L, Greene R, Leitao S. Impact of bereavement care and pregnancy loss services on families: findings and recommendations from Irish inquiry reports. Midwifery. 2020;91:102841.

(48) O’Connor E, Helps Ä, Greene R, O’Donoghue K, Leitao S. Characteristics of serious incident management team (SIMT) reviews in maternity units. Irish Medical Journal. 2025;118(5):P72.

(49) Helps Ä, O’Donoghue K, O’Connell O, Leitao S. Bereaved parents involvement in maternity hospital perinatal death review processes: ‘Nobody even thought to ask us anything’. Health Expectations. 2023;26(1):183–98.

(50) Helps Ä, Leitao S, Greene R, O’Donoghue K. Perinatal mortality audits and reviews: Past, present and the way forward. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020;250:24–30.

(51) O’Connor E, Helps Ä, Greene R, O’Donoghue K, Leitao S. Maternity staff views on implementing a national perinatal mortality review tool: understanding barriers and facilitators. Journal of Perinatal Medicine. 2025;53(4):454–66.

(52) O’Connor E, Leitao S, Fogarty AP, Greene R, O’Donoghue K. A systematic review of standardised tools used in perinatal death review programmes. Women and Birth. 2024;37(1):88–97.