Background Confidential peer reviews seek to identify the causes of adverse outcome through an impartial and blame free examination of the standard of care and avoidability of the outcome.

Method Five streams of confidential case note reviews were conducted, focusing on (1) stillbirths with fetal growth restriction; (2) perinatal deaths to migrant mothers; (3) perinatal deaths in units with high mortality; (4) all intrapartum deaths; and (5) neonatal deaths examined on behalf of local safeguarding children boards. Congenital anomalies were excluded. Cases were anonymised and multidisciplinary, independent review panels were constituted from a bank of 107 professionals.

Results Panels identified significant substandard care in 165 of 177 cases, and in 105 (59.3%) the outcomes were considered to be potentially avoidable. The main findings related to antenatal risk assessment and management plan, detection of intrauterine growth restriction, CTG interpretation, oxytocin hyperstimulation, failure to escalate or expedite delivery, non-NLS neonatal resuscitation, or poor bereavement care, follow-up or plan for future pregnancies. For a subset of cases, unit based assessments were compared with those from review panels. This found that most units' review procedures are currently not well standardised, and miss over three-quarters of substandard care points identified by the independent panels.

Conclusion Confidential case reviews are a powerful means for identifying upstream causes, instances of substandard care and systems failures leading to stillbirth or neonatal death. There is an urgent need for units to standardise in house case review, and improve their own ability to derive and implement learning points from adverse outcome.