Purpose

Consistent concerns have been raised about the effectiveness of Trust board oversight of their maternity and neonatal services. Our report has raised questions about the ability of Trust boards to fully understand and monitor the quality and safety of these services.

We have provided this short guide to support board members; offering an overview of the key data sources available to them, with a focus on Trust level data relevant to perinatal mortality. Our aim is to help board members easily navigate the information they need and support them to carry out their oversight role with confidence.

Accessing data on baby deaths in your Trust 

MBRRACE-UK (Mothers and Babies: Reducing risk through audits and confidential inquiries across the UK) – surveillance data

Data on stillbirths, neonatal deaths and maternal deaths are available publicly here, displayed as an interactive national dashboard, where data can be filtered by country, region, neonatal network and Trust/Health Board. National perinatal surveillance data are published annually, typically in May, and accompanied by a State of the Nation report, available here.

In addition to the annual UK-wide perinatal mortality surveillance reports, MBRRACE-UK produces tailored reports for each Trust/Health Board, and which are only available to registered users of the MBRRACE-UK surveillance system. For information on how to access the report, please see p.33-34 of this guidance.

There is a two-year time lag in the reporting perinatal surveillance data, so 2024 data will be published in 2026. However, MBRRACE also has a real-time data monitoring tool which allows organisations to filter and summarise the perinatal deaths as they are reported to MBRRACE. More detail on how to use the tool is available here, on p.35-42.
Both the tailored reports and real-time data monitoring tool can be accessed on the MBRRACE-UK website. For details on how to log in, please see p.7 of this guidance.

Maternity Outcomes Signal System (MOSS)

MOSS is NHS England’s near real-time safety signal system that uses statistical methods to detect unusual patterns in routinely collected intrapartum outcome data – including term stillbirths, neonatal deaths and wider adverse event trends to identify emerging safety issues early. MOSS tracks whether there are more adverse events than expected, issuing an amber (95% chance that the increase in events is real and not due to chance) or red (99% that the increase is real and not due to chance) alert. MOSS automatically emails registered users from Trusts, ICBs, and regional and national leadership when a signal occurs. Trust board members who should be registered, given their accountability for maternity safety and oversight, include:

• Executive Trust Board Safety Champion
• Chief Medical Officer
• Chief Nurse

Each alert should trigger a rapid safety check, which must be completed within eight working days.

A guide to how authorised viewers can access MOSS is available here.

An interpretation guide for MOSS charts are available here.

Information on the MOSS standard operating procedures are available here.

Insight into other maternity and neonatal outcomes in your Trust

NHS England – National Maternity Dashboard

The National Maternity Dashboard, available here, is an interactive dashboard that displays Clinical Quality Improvement Metrics (CQIMs) from the Maternity Services Data Set (MSDS), National Maternity Indicators (NMIs) from external audits, and provider‑level demographic data such as maternal age, BMI, ethnicity, bookings, and births. It is specifically designed to support benchmarking and identify areas for clinical quality improvement across maternity services.

National Neonatal Audit Programme (NNAP)

NNAP reports on key aspects of neonatal care in NHS neonatal units across Great Britain, including outcomes such as mortality and major morbidities, as well as optimal perinatal care measures, such as maternal breastmilk feeding, parental partnership, and neonatal nurse staffing. Annual reports are published online, available here, and data are available at individual unit and neonatal network level via the NNAP data viewer, alongside summaries of the audit’s core performance metrics.

National Maternity & Perinatal Audit (NMPA)

The NMPA is a large‑scale national clinical audit covering maternity services across England, Scotland, and Wales. Its purpose is to evaluate maternity and neonatal care processes and outcomes, identify unwarranted variation, and highlight areas for improvement using clinical audit data. NMPA provides risk-adjusted Trust-level comparisons and outlier flag for metrics with case-mix adjusted proportions such as small for gestational babies (all babies at term who are <10^th centile, who are born at or after 40+0 weeks), Apgar score <7 at 5 minutes, third and fourth perineal tears, post-partum haemorrhage >1500ml, and breast milk (live born babies who receive breast milk for the first feed). The audit uses routinely collected clinical data to assess adherence to guidelines and quality standards, supporting system‑level insight and long‑term quality improvement. Trust-level data can be accessed here.

Maternity and Neonatal Equalities Dashboard

The Maternity and Neonatal Equalities Dashboard, accessible here, brings together MSDS, CQC, and MBRRACE‑UK data to highlight disparities in maternity and neonatal care in England.  The dashboard includes service provision data – such as gestational age at booking and mode of birth – alongside data on service user experience and outcomes (stillbirths, neonatal deaths, maternal deaths, and preterm births). All measures are disaggregated by deprivation and ethnicity.

Patient and staff experience

NHS England Staff Survey

NHS England’s staff survey is published annually and provides a snapshot of people’s experience working in the NHS. Detailed results are available for each NHS Trust here, which can be benchmarked against the national results and compared with previous years. Data can also be disaggregated by staff group, although for maternity and neonatal services it is only possible to disaggregate results for midwives and no other professional group.

Care Quality Commission (CQC) Maternity Survey 

The CQC survey looks at the experience of people accessing maternity services. Data are available for individual Trusts here, alongside a comparison to the national data, and are published annually.  It is important to note that the survey does not include the experience of parents whose babies are stillborn or die in the neonatal period.

Learning from reviews and investigations in your Trust

Perinatal Mortality Review Tool (PMRT)

The PMRT aims to standardise hospital reviews of perinatal deaths, to enable parents to be part of the process, if they choose, and follow a structured process of review, learning, reporting and actions to improve future care. The tool can generate Trust-level summary reports which summarises:

• The deaths reviewed, by gestational age and type of death
• The grading of care (whether the care provided was deemed to have contributed to the outcome), by gestational age and type of death
• The causes of death
• The issues raised by reviews
• The number of staff involved in reviews, and their specialities
• The top contributory factors identified as relevant to the deaths.

The report can be access through the MBRRACE-UK website. For further information on the reports please see p.42-43 of this guidance. There are also training courses on how to use the tool, which can be accessed here.

Maternity and Newborn Safety Investigations (MNSI)

The Maternity and Newborn Safety Investigations (MNSI) programme independently investigates serious maternity and newborn safety incidents, such as intrapartum stillbirths, early neonatal deaths, severe brain injuries, and maternal deaths, to understand what occurred, why, and what improvements are needed.

MNSI provides external insight into the safety and quality of Trusts services, enabling board members to evaluate the effectiveness of escalation, risk management, and governance processes, confirm whether key safety risks are being addressed, and use independent learning to drive targeted improvements and strengthen oversight.

MNSI gives Trust boards access to independent investigation reports, national safety findings, thematic learning, and strategic guidance, available here or will be shared directly with Trusts following investigations.