Background Confidential enquiries have identified an urgent need to improve unit based case reviews of perinatal deaths. SCOR (standardised clinical outcome review) is a software programme developed to improve the identification of substandard care factors and learning points at unit level.

Method The application assesses management in each phase of perinatal care, identifies a taxonomy of care issues and prompts auditable action plans. It is completed by the risk manager on behalf of a multi-disciplinary unit review team. Software and training was implemented in 2011 across 17 NHS units, and a preliminary evaluation and user survey was undertaken in late 2012.

Results In total, 302 stillbirths and 130 neonatal deaths had been entered. The main themes identified by SCOR related to documentation, antenatal screening and surveillance, risk assessment and management, organisational issues and bereavement care. Responses to the evaluation survey were received from 15 of the 17 pilot sites (88%) (Table).

Conclusion SCOR is a useful tool for lessons from adverse perinatal outcomes to be learnt and implemented for improved safety in maternity care.