The objective of this study was to identify adverse social and medical factors contributory to post-perinatal deaths and at which stage of the case study each factor was found. The sources of information assessed were: (i) recorded data from case notes, laboratory and postmortem findings, and (ii) created information from (a) home interview and (b) case discussion held in the family doctor's office. The deaths were categorized into seven clinicopathological groups and adverse factors into general demographic and personal psychosocial. Among the 87 sequential post-perinatal infant deaths, 325 adverse factors were identified; of these, 125 (38%) were judged to be actionable by the carers. Of 183 (56%) adverse factors found in the case notes, only 36 were actionable. Forty-five more adverse factors were found at home interview; 26 (58%) of these were actionable. At case discussion another 97 adverse factors were revealed; 63 (65%) were actionable, thus proving the most important source of actionable information.