Quality improvement vignette: Sharing learning from neonatal mortality reviews in Wales

Author

Dr Jennifer Calvert, Clinical Lead, Wales Maternity and Neonatal Strategic Clinical Network.

Overview

Neonatal units across Wales are required to review every neonatal death using the Perinatal Mortality Review Tool (PMRT) as part of a consistent approach to learning and quality improvement. Following local review, cases are presented to the monthly Neonatal Mortality Shared Learning Forum (NMSLF), hosted by the Maternity and Neonatal Strategic Network.

The forum brings together a broad multidisciplinary team, including all members of the perinatal team, ambulance service colleagues, other clinical specialists, and, where relevant, colleagues from outside Wales. Using a recently updated standardised PMRT-based template, unit representatives present anonymised summaries of local reviews, highlighting examples of good practice, lessons learned, and actions arising from Health Board reviews.

By sharing learning across organisations, the forum enables participants to identify recurring themes that may not be apparent from individual cases alone and to develop wider recommendations for service improvement. Learning points are collated after each meeting and circulated across the network, supporting the spread of good practice and continuous improvement in neonatal care throughout Wales.