Publication of the Pregnancy Loss Review

The 2nd of March 2018 was a historic day, as the first ever review of baby loss was launched in England. This was commissioned by the Secretary of State for Health and Social Care, the Rt Hon Jeremy Hunt, to investigate the care and support of anyone who experiences pre-24-week loss. The parameters of the review were intentionally wide, to cover not only clinical care, but also to include all support, workforce and more. Zoe Clark-Coates MBE BCAh, our global CEO and Samantha Collinge RM, a Lead Bereavement Midwife were appointed to co-chair and author this monumental review.

Saturday the 22nd of July 2023, almost five and a half years on, marked the publication of the eagerly awaited ‘Pregnancy Loss Review’, and it was laid in Parliament on the 24th of July 2023.

Over the past five and a half years, Zoe has travelled the length and breadth of England, visiting hospitals and clinics, shadowing doctors, nurses, midwives and other healthcare professionals. She has met with countless experts, Royal Colleges, charities, and leads from across the NHS and beyond. She has heard from thousands of bereaved families from around the country, who have bravely shared their heart-breaking stories. She has been with patients as they received the devastating news that their baby had died, journeyed with them through procedures, surgery, and aftercare, so she could witness first-hand current care, and advise on how things could be improved. She has spent countless hours in staff rooms, treatment rooms, theatres and clinics to ensure that all of the recommendations would make a difference to patients, partners and healthcare professionals.

The review showcased how many incredible individuals there are working across primary and secondary care; people who go above and beyond to support families experiencing baby loss. Sadly, it also highlighted many areas in which the clinical care and support offered has failed and tragically let down millions of people. Zoe and Sam have used their combined 60-years of professional experience, alongside their lived experience of being mothers who have personally journeyed baby loss, to propose seventy three vital recommendations. In an instant show of support, the government accepted them all, and have committed to implement the recommendations in stages, assisted by Zoe and Sam.

If you have followed the charity’s work over the past decade, you will have seen us campaign for 24-hour access to care, the introduction of a clinical loss kit, support and investigations for anyone who has experienced one baby loss, improved bereavement training and facilities, bereavement leave and more. As a charity we have been a lone voice leading a campaign over the past 9-years, calling for the introduction of an optional, official, government issued ‘Certificate of Life’ available to anyone who loses a baby pre-24-weeks gestation . A certificate does more than just honour and recognise a life, it shows the world that baby loss is not just a medical incident, but for many the loss of a families hopes, dreams and their longed-for child. We have been working with Baroness Floella Benjamin DBE on this over the past seven years, and have a Bill in the House of Lords to see this introduced. Zoe and Sam were able to include these key ideas from the outset of the review.

As you may have seen ‘Certificates of Life’ for anyone who experiences a pre-24-week loss, 24-hour access to EPAU (Early Pregnancy Assessment Unit), the ‘CCC – Compassionate Clinical Care’ Kit, workforce training and support, a tiered level of medical investigation following one loss, and improvements in mental health care for patients and staff, are just a handful of the recommendations Zoe and Sam have stated need to be introduced. The government have confirmed that all of the recommendations have been accepted and will be implemented, so we know that radical improvement is on its way. Some of the changes should happen fairly quickly, whilst others will take many years to fully roll out, due to finance, infrastructure and workforce. What is important is that all change is consistent, sustainable and removes the inequalities that currently exist.

On behalf of the charity, we would like to thank all of the brave individuals who shared their stories, and lent their voices to campaign for change. Thank you to all of the incredible NHS and medical staff who shared their experiences (good and bad), as well as their frustrations and ideas; all of these contributed to Zoe and Sam proposing ground-breaking measures. Thank you to the Rt Hon. Jeremy Hunt and the successive Health Secretaries and Ministers for their support, and all of our charity Ambassadors who stood with us demanding change.

Finally, on behalf of the trustees and team at the Mariposa Trust (Saying Goodbye), and on behalf of the millions of people in the UK who have experienced baby loss, thank you to Zoe and Sam. Your passion to see this review delivered, and commitment to action change, has led to this review being laid in parliament, and your recommendations being fully accepted by the government. Past, present and future generations, will all benefit from your dedication and determination to improve the care and support of anyone affected by baby loss.

Over the coming weeks and months, Zoe will be sharing on this website, more about the recommendations and why they are so vital. As expected, with any ground-breaking news story, there is a substantial amount of accurate and inaccurate information about the recommendations being shared in the media and on social media, and Zoe is keen to ensure that parents and healthcare professionals understand what has been recommended, and why. So watch this space, as it will be a safe and trusted source of correct information. If you are a healthcare professional and need guidance, please email [email protected]