Parent feedback questionnaire

We are very sorry for your loss, and we appreciate that this is an extremely difficult time for you.

This questionnaire is for parents who have experienced the loss of their baby/babies during pregnancy or shortly after birth. Please complete as much or as little of the form that you are able to. Some questions may not be relevant to your experience. Your feedback will help us to improve bereavement services in maternity across Leeds.

Please tick the relevant box for each question (the survey will take around 10 minutes to complete) and write any comments you might have. All information given will remain anonymous unless you wish to provide your contact details at the end of this questionnaire.

If you would like to discuss any aspects of your care, please contact:

Alison Bowes
Specialist Bereavement Midwife
Haamla Office, Antenatal Clinic, Level 4, Gledhow Wing,
St James's University Hospital, Beckett Street, Leeds, LS9 7TF
Tel: 07920029180
Email: alison.bowes1@nhs.net

1. What is your relationship to the baby / babies who have died?

2. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were cared for in an appropriate environment during the birth of my/our baby/babies	I/we were cared for in an appropriate environment during the birth of my/our baby/babies Strongly agree	I/we were cared for in an appropriate environment during the birth of my/our baby/babies Agree	I/we were cared for in an appropriate environment during the birth of my/our baby/babies Undecided	I/we were cared for in an appropriate environment during the birth of my/our baby/babies Disagree	I/we were cared for in an appropriate environment during the birth of my/our baby/babies Strongly disagree	I/we were cared for in an appropriate environment during the birth of my/our baby/babies This was not relevant to my situation

Comments:

3. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
Staff communicated with me/us in a sensitive way	Staff communicated with me/us in a sensitive way Strongly agree	Staff communicated with me/us in a sensitive way Agree	Staff communicated with me/us in a sensitive way Undecided	Staff communicated with me/us in a sensitive way Disagree	Staff communicated with me/us in a sensitive way Strongly disagree	Staff communicated with me/us in a sensitive way This was not relevant to my situation

Comments:

4. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we felt confident in the staff caring for me/us	I/we felt confident in the staff caring for me/us Strongly agree	I/we felt confident in the staff caring for me/us Agree	I/we felt confident in the staff caring for me/us Undecided	I/we felt confident in the staff caring for me/us Disagree	I/we felt confident in the staff caring for me/us Strongly disagree	I/we felt confident in the staff caring for me/us This was not relevant to my situation

Comments:

5. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were able to be involved in any decisions about my/our baby/babies	I/we were able to be involved in any decisions about my/our baby/babies Strongly agree	I/we were able to be involved in any decisions about my/our baby/babies Agree	I/we were able to be involved in any decisions about my/our baby/babies Undecided	I/we were able to be involved in any decisions about my/our baby/babies Disagree	I/we were able to be involved in any decisions about my/our baby/babies Strongly disagree	I/we were able to be involved in any decisions about my/our baby/babies This was not relevant to my situation

Comments:

6. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were fully informed about what had happened to my/our baby/babies	I/we were fully informed about what had happened to my/our baby/babies Strongly agree	I/we were fully informed about what had happened to my/our baby/babies Agree	I/we were fully informed about what had happened to my/our baby/babies Undecided	I/we were fully informed about what had happened to my/our baby/babies Disagree	I/we were fully informed about what had happened to my/our baby/babies Strongly disagree	I/we were fully informed about what had happened to my/our baby/babies This was not relevant to my situation

Comments:

7. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were given the opportunity to spend the time I/we wanted with my/our baby/babies	I/we were given the opportunity to spend the time I/we wanted with my/our baby/babies Strongly agree	I/we were given the opportunity to spend the time I/we wanted with my/our baby/babies Agree	I/we were given the opportunity to spend the time I/we wanted with my/our baby/babies Undecided	I/we were given the opportunity to spend the time I/we wanted with my/our baby/babies Disagree	I/we were given the opportunity to spend the time I/we wanted with my/our baby/babies Strongly disagree	I/we were given the opportunity to spend the time I/we wanted with my/our baby/babies This was not relevant to my situation

Comments:

8. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were given the opportunity to create memories with my/our baby/babies without feeling rushed (eg photography, foot and handprints, washing and dressing my/our baby/babies)	I/we were given the opportunity to create memories with my/our baby/babies without feeling rushed (eg photography, foot and handprints, washing and dressing my/our baby/babies) Strongly agree	I/we were given the opportunity to create memories with my/our baby/babies without feeling rushed (eg photography, foot and handprints, washing and dressing my/our baby/babies) Agree	I/we were given the opportunity to create memories with my/our baby/babies without feeling rushed (eg photography, foot and handprints, washing and dressing my/our baby/babies) Undecided	I/we were given the opportunity to create memories with my/our baby/babies without feeling rushed (eg photography, foot and handprints, washing and dressing my/our baby/babies) Disagree	I/we were given the opportunity to create memories with my/our baby/babies without feeling rushed (eg photography, foot and handprints, washing and dressing my/our baby/babies) Strongly disagree	I/we were given the opportunity to create memories with my/our baby/babies without feeling rushed (eg photography, foot and handprints, washing and dressing my/our baby/babies) This was not relevant to my situation

Comments:

9. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we felt that my baby/babies were treated with respect and sensitivity	I/we felt that my baby/babies were treated with respect and sensitivity Strongly agree	I/we felt that my baby/babies were treated with respect and sensitivity Agree	I/we felt that my baby/babies were treated with respect and sensitivity Undecided	I/we felt that my baby/babies were treated with respect and sensitivity Disagree	I/we felt that my baby/babies were treated with respect and sensitivity Strongly disagree	I/we felt that my baby/babies were treated with respect and sensitivity This was not relevant to my situation

Comments:

10. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
My/our family members and my/our other children were included appropriately in my/our care	My/our family members and my/our other children were included appropriately in my/our care Strongly agree	My/our family members and my/our other children were included appropriately in my/our care Agree	My/our family members and my/our other children were included appropriately in my/our care Undecided	My/our family members and my/our other children were included appropriately in my/our care Disagree	My/our family members and my/our other children were included appropriately in my/our care Strongly disagree	My/our family members and my/our other children were included appropriately in my/our care This was not relevant to my situation

Comments:

11. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were offered the opportunity for a post mortem examination	I/we were offered the opportunity for a post mortem examination Strongly agree	I/we were offered the opportunity for a post mortem examination Agree	I/we were offered the opportunity for a post mortem examination Undecided	I/we were offered the opportunity for a post mortem examination Disagree	I/we were offered the opportunity for a post mortem examination Strongly disagree	I/we were offered the opportunity for a post mortem examination This was not relevant to my situation

Comments:

12. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were provided with sufficient information and support to make an informed decision about whether to proceed with a post mortem examination	I/we were provided with sufficient information and support to make an informed decision about whether to proceed with a post mortem examination Strongly agree	I/we were provided with sufficient information and support to make an informed decision about whether to proceed with a post mortem examination Agree	I/we were provided with sufficient information and support to make an informed decision about whether to proceed with a post mortem examination Undecided	I/we were provided with sufficient information and support to make an informed decision about whether to proceed with a post mortem examination Disagree	I/we were provided with sufficient information and support to make an informed decision about whether to proceed with a post mortem examination Strongly disagree	I/we were provided with sufficient information and support to make an informed decision about whether to proceed with a post mortem examination This was not relevant to my situation

Comments:

13. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we felt assured that the GP and community midwife had been informed of my/our loss before leaving the hospital	I/we felt assured that the GP and community midwife had been informed of my/our loss before leaving the hospital Strongly agree	I/we felt assured that the GP and community midwife had been informed of my/our loss before leaving the hospital Agree	I/we felt assured that the GP and community midwife had been informed of my/our loss before leaving the hospital Undecided	I/we felt assured that the GP and community midwife had been informed of my/our loss before leaving the hospital Disagree	I/we felt assured that the GP and community midwife had been informed of my/our loss before leaving the hospital Strongly disagree	I/we felt assured that the GP and community midwife had been informed of my/our loss before leaving the hospital This was not relevant to my situation

Comments:

14. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were given the contact details for the Bereavement Midwife	I/we were given the contact details for the Bereavement Midwife Strongly agree	I/we were given the contact details for the Bereavement Midwife Agree	I/we were given the contact details for the Bereavement Midwife Undecided	I/we were given the contact details for the Bereavement Midwife Disagree	I/we were given the contact details for the Bereavement Midwife Strongly disagree	I/we were given the contact details for the Bereavement Midwife This was not relevant to my situation

Comments:

15. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were given details of local and national Bereavement Support Groups before discharge from hospital	I/we were given details of local and national Bereavement Support Groups before discharge from hospital Strongly agree	I/we were given details of local and national Bereavement Support Groups before discharge from hospital Agree	I/we were given details of local and national Bereavement Support Groups before discharge from hospital Undecided	I/we were given details of local and national Bereavement Support Groups before discharge from hospital Disagree	I/we were given details of local and national Bereavement Support Groups before discharge from hospital Strongly disagree	I/we were given details of local and national Bereavement Support Groups before discharge from hospital This was not relevant to my situation

Comments:

16. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
I/we were given time and an opportunity to express my/our wishes clearly regarding arrangements for my/our baby/babies (e.g. funeral or memorial service)	I/we were given time and an opportunity to express my/our wishes clearly regarding arrangements for my/our baby/babies (e.g. funeral or memorial service) Strongly agree	I/we were given time and an opportunity to express my/our wishes clearly regarding arrangements for my/our baby/babies (e.g. funeral or memorial service) Agree	I/we were given time and an opportunity to express my/our wishes clearly regarding arrangements for my/our baby/babies (e.g. funeral or memorial service) Undecided	I/we were given time and an opportunity to express my/our wishes clearly regarding arrangements for my/our baby/babies (e.g. funeral or memorial service) Disagree	I/we were given time and an opportunity to express my/our wishes clearly regarding arrangements for my/our baby/babies (e.g. funeral or memorial service) Strongly disagree	I/we were given time and an opportunity to express my/our wishes clearly regarding arrangements for my/our baby/babies (e.g. funeral or memorial service) This was not relevant to my situation

Comments:

17. Please select one option for the statement below:

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	This was not relevant to my situation
The follow up appointments took place in a sensitive location	The follow up appointments took place in a sensitive location Strongly agree	The follow up appointments took place in a sensitive location Agree	The follow up appointments took place in a sensitive location Undecided	The follow up appointments took place in a sensitive location Disagree	The follow up appointments took place in a sensitive location Strongly disagree	The follow up appointments took place in a sensitive location This was not relevant to my situation

Comments:

Parent feedback questionnaire

1. What is your relationship to the baby / babies who have died?

2. Please select one option for the statement below:

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18. Tell us about any part of the care you received that was most helpful?

19. Is there any part of your care that could have been improved?

20. Is there anything you would like to see introduced into the service or anything else you would like to feedback on?