Background and Aims Neonatal care has developed dramatically over the last few decades. In spite of this, the neonatal mortality remains high. As clinicians we strive to deliver high quality care and by reviewing the care in all neonatal deaths we hope to identify the avoidable risk factors, areas of good practice and areas for improving care and optimising future service delivery.
Methods Patient notes of all neonates died over one year (1st Jan 2010–31st Dec 2010) period in a tertiary neonatal unit in UK were reviewed by members of a multidisciplinary team. Reviews were performed using a structured format assessing all areas of care including resuscitation, clinical management, transfer, communication and documentation.
Results 1018 infants were admitted to the neonatal unit, 878 infants were in-born and 140 infants were ex-utero transfers. Most deaths (14 infants (1.3%)) occurred within first seven days of life, 8 infants (0.7%) died in the late neonatal period and 5 infants (0.5%) died after 28 completed days.
Several areas of good practices were identified, including evidence of good multi-disciplinary team working. Key themes were identified as areas for improvement including documentation and continuity of care at consultant level for infants with complex needs and longer stay. An annual report summarising all cases and recommendations was produced.
Conclusion Mortality case reviews are an important source of learning. In order to successfully influence the service development these reviews must be structured, include input from a multi-disciplinary team and result in specific and achievable recommendations.