Supplementary File

This file contains quotations from participants that illustrate the issues raised in the paper.

1. Daily interactions with bereaved parents (pg.5-6.)

‘If a parent loses a single baby, you know, you don’t really see them once they’ve got over the initial em, dealing with the situation and the initial bereavement bit and after that they tend to go home …you don’t see how they grieve and how they react to it. But with a multiple loss, you know, they may have the other twin still on the unit so you are still involved with that family, so there’s the bereavement process and the grief process that you may not have seen with a single baby. They still have to think about that baby, coming in and caring for that baby … but with this huge loss and this grief going on at the same time.’(Senior staff nurse)

i). Acknowledging bereavement(pg.6-7)

‘I always waited until parents said something to me…you wouldn’t necessarily bring that up…how do I approach the subject? Do I even approach the subject? I don’t know enough to actually help them and how to steer a conversation with them.’(Nursery nurse)

‘If we didn’t feel uncomfortable because we thought we had the whole issue [talking to bereaved parents] wrapped up, actually we have lost the plot. The nature of trying to understand how parents are and how they themselves are changing from day to day should never leave us in a comfort zone.’(Medical professional)

‘I never heard anybody else mention Tamba and somebody [fellow nurse] said to me once:”Oh [name] you know, that’s good that you said that, youknow, they are the people who understand what they are going through…’ (Experienced Nurse)

ii). Maintaining the twin identity of the survivor (pg. 6-7)

‘There is a tendency for the memory of the dead co-twin to become less at the forefront of the mind of health professionals...your job is to execute the care and wellbeing of the surviving twin…I think there comes a point where medical staff want to stop treating the survivor as a twin, they don’t want to deal with the emotional baggage’. (Medical professional)

‘If you’ve got triplets and somebody loses a triplet, I mean you wonder whether people...the general feeling around the place is, ‘Well she’s still got twins and that’s kind of two better than [none]...’ I think we kind of water down our acknowledgement depending on how many live babies there are.’ (Experienced midwife)

2. Understanding bereavement and trauma (pg.7-8)

i). Complex grieving (pg. 7)

‘...if you’ve got a multiple it is that conflict of emotion, it’s the thrill of having a live baby but also the bereavement with your other one so yes, it is different [from a singleton loss].’ (Experienced midwife)

‘I always felt I mismanaged that situation emotionally for her because for me it as all about the 28 week baby that was alive…I felt I gave the best practical care but I always felt I hadn’t acknowledged [twin’s] demise in the way that I should....maybe we should be dealing with that grief long before the baby is actually born. The sole focus is upon [the live baby]...we’ve forgotten about that [the deceased] baby, we are going to scan the live one, plan the delivery of the live one...’ (Midwife)

ii). Education and experience (pg. 8)

‘[Death and bereavement] is a massive part of nursing, especially if you work in an environment such as intensive care where you are going to get babies who die…you need to learn how to deal with that situation and yes, I think a lot of it comes from experience …but there needs to be a lot more. Our understanding of the bereavement process for example the mental health side of things’.(Senior nurse)

3.Sensitive care practices (pg. 8-9)

‘We always try not to introduce new procedures on the surviving twin on the day of the funeral…also don’t change beds etc. in case the remaining baby becomes unstable and this would cause parents to worry.(Medical professional)

‘From a twin point of view, I’ve tried to get the photo of the two of them together, which they’ll [parents] never have. I don’t know if we necessarily think about that on the unit’.(Staff nurse)

i). Utilising bereavement services (pg.9-10)

‘I think still there is a stigma attached to going and seeing a health professional to talk about psychological support so I’m sure there are a lot of couples out there who would benefit from speaking to somebody who is not an immediate member of the kind of care team but they probably don’t access the service because they’re not sure what it would provide and they’re worried about what it means about themselves.’(Medical professional)

‘We need awareness of how to use what [bereavement services] we have and when it is appropriate to use them.’(Staff nurse).

ii). Communicating information to bereaved parents (pg. 10)

‘They tend to only hear the first few seconds of information especially if it’s a big change or something like that so, if you say…‘the baby needs an operation’, that’s the first thing you say to them for example, they hear nothing else after that you know, so I always say they should write down any questions they have’. (Medical professional)

‘It’s so difficult to judge when you’re with them [parents] for about half an hour…in that, is that genuinely how they feel? Is it just how they cope? Is it just that they want to get through this chat with the doctor?’ (Medical professional)

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