Abstract

In Ireland, there were 335 perinatal deaths (stillbirths and neonatal deaths) in 2019. These deaths are devastating for parents and families, with long-lasting emotional consequences. To investigate these deaths and identify contributory factors, local hospital-based perinatal death reviews–as well as national perinatal mortality audits–are carried out. In certain circumstances, an external inquiry may be commissioned. Reports with recommendations are published. In Ireland, there is currently no standardised format to the recommendations or their implementation. Furthermore, the involvement of bereaved parents in local reviews is poorly explored. We analysed the methodology and structure of perinatal mortality audits, local reviews and inquiries, as well as recurrent themes in the recommendations of the published reports, and the involvement of bereaved parents. We evaluated review processes in the 19 maternity units/hospitals nationally and interviewed bereaved parents. Perinatal mortality processes, including reviews, need to be standardised nationally. Suggestions to achieve this include the adaptation of the National Incident Management Framework specifically to the maternity setting; implementation of an electronic review tool for perinatal deaths; and an assessment of the feasibility of a national perinatal Coroner for Ireland. The inclusion of parents in perinatal mortality reviews needs to be addressed and resourced.