A summary of the new programme aimed at reducing avoidable injuries and deaths as a result of clinical errors during childbirth.
The Royal College of Obstetricians & Gynaecologists (RCOG) launched a new 5 year programme towards the end of 2014 in an effort to reduce the number of babies who die or incur severely disabling injuries during their birth at term.
In the UK the statistics show that on average around 500 babies per year either die or are left with a severe brain injury because there is a clinical error in their care during labour, and not as a result of any natural cause. The RCOG states that they “do not accept that all of these are unavoidable tragedies” and therefore have launched this new project to try to reduce “unnecessary suffering and loss of life by 50% by 2020”.
The figures put forward by the RCOG make for very upsetting reading; the trauma and pain caused to expectant families when their child’s birth goes catastrophically wrong is hard to contemplate. The impact of a stillbirth or neonatal death is well documented by the national charity SANDS (the Stillbirth and Neonatal Deaths Society). If a baby has suffered severe oxygen deprivation at birth then they may suffer a brain injury with a subsequent diagnosis of cerebral palsy, with lifelong implications for the child and their family.
The situation is made all the more difficult when parents are informed that their child’s death or brain injury could have been avoided had it not been for medical errors on the part of clinical staff.
Due to the severity of the consequences when deliveries are incompetently handled the RCOG has commendably decided to aim to change the status quo, as these high figures cannot be considered acceptable within modern medical practice.
At present all hospitals collate their own statistics and information relating to a critical incident or adverse outcomes in patient care. This information may be disseminated amongst clinical staff at that individual Trust, but is not shared on a national level.
The Each Baby Counts team with therefore collate and pool together the findings of local investigations in order to share information on a national level, in an effort to improve learning and improve practice across the UK.
Jacque Gerrard, director for England at the Royal College of Midwives said the initiative “will go a long way towards sparing families the immense grief and stress that stillbirth and poor neonatal health outcomes have on families“.
“It is vital that we learn the lessons from each of these tragic events,” she said “We must also ensure that what we learn is shared and any actions implemented across the whole country.”
I am sure all medical professionals involved in the care of women and their babies will welcome this initiative, which for the first time will allow for the review of local complications on a national level and facilitate information sharing. The success of this project will of course depend on obstetricians and midwives being open about complications in cases and being willing to listen and take on board the lessons learnt by others, which we hope will be adopted.
We hope that the sharing of information at national level will also ensure that there is consistency of care across the UK. This will avoid reports of “postcode lotteries” and ensure patients can feel happy that wherever their treatment is provided it will be of the same standard.