Abstract

Reviews into why babies have died can help to provide better care, end preventable deaths and provide answers for bereaved parents. Many parents are not involved in the review process. We interviewed 32 staff from three maternity units in Ireland between May and December 2022. We wanted to find out what they thought about review systems currently in place, parent involvement in reviews and standardising the review system. Staff interviewed included doctors, midwives, patient advocates and risk managers. This paper focuses on themes around communication with parents about reviews and their involvement in hospital review processes. Participants felt that parents were not involved enough in the review process and that communication with parents about reviews needed improvement. A parent advocate was viewed as important for guidance and support for parents. Other things that would help included an easy-to-use, electronic review form for a case review and providing education to staff about the review process. Challenges included local resistance to changing the process and lack of time to complete reviews into baby deaths. Overall, we found that reviews into baby deaths are not standardised across Irish maternity hospitals/units. Communication with parents and parent involvement in reviews could and should be improved. We identified areas for improvement that should be addressed before implementing any changes to the review system.