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New report says investigations into baby deaths in the UK are not good enough

  • Hannah Blackwell summarises the recent report from the Royal College of Obstetricians and Gynaecologists, which highlights that there are too many poor quality investigations into babies who are stillborn or suffer severely brain damaged during labour.

    By Hannah Blackwell

Following on from my colleague, Ali Clock’s blog yesterday on the MBRACE-UK Report which highlighted significant variations in the rates of stillbirths and neonatal deaths across the UK, a further report has just been published by the Royal College of Obstetricians and Gynaecologist (RCOG) highlighting that when stillbirth does occur, the investigations into the cause of those still births are often of poor quality.

Scope of the most recent report

The RCOG inquiry ‘Each Baby Counts’ and has been set up to ensure lessons are learned when something does go wrong.  The report published at this stage is a preliminary report and the final report is due in 2017.  The aim is, by 2020, to halve the number of babies who die or are left severely disabled.

The enquiry is looking at stillbirths, neonatal deaths and brain injury occurring at the time of birth (after 37 weeks).  These incidents are usually investigated within an individual Trust and the ‘Each Baby Counts’ project team will, for the first time, bring together the results of those local investigations to understand the bigger picture and share the lessons learned across the UK.

The inquiry team intend to collect and analyse data from all UK obstetric units to identify lessons learned to improve future care.  They will then be able to make recommendations on how to improve practice at a national level.  More than 900 cases have already been referred to the inquiry team.

Preliminary Report Findings

Out of 800,000 births after 37 weeks of pregnancy in the UK during 2015, there were;

  • 655 babies classified as having severe brain injuries;
  • 147 neonatal deaths (within 7 days of birth);
  • 119 stillbirths.  In all cases, the babies had been healthy before labour began.

Of the 204 investigations carried out locally at hospitals following problems during labour, which have subsequently been reviewed by the inquiry team – 27% were found to have been of poor quality.  The review has also been looking at the number of cases where parents had been involved in the investigations – nearly three quarters of the 599 reviews did not involve the parents in any meaningful way.  Professor Alan Cameron, Vice Precedent of the RCOG and a Consultant Obstetrician in Glasgow has commented, “When the outcome for parents is the devastating loss of a baby, or a baby born with a severe brain injury, there can be little justification for the poor quality of reviews found”.

What More Will Be Done?

Health Minister Ben Gummer said the findings of the preliminary report were “unacceptable”.  He said, “We expect the NHS to review and learn from every tragic case, which is why we are investigating a new systems to support staff to do this and help ensure far fewer families have to go through this heartache”.

Considered together with the recommendations from the recent MBRACE-UK report it seems that ensuring good quality investigations when babies have suffered severe injury or died during labour is a key step in seeking to reduce and prevent future injuries and deaths in similar circumstances.

However, as my colleague Ali highlighted in her recent blog, the MBRACE-UK report also highlighted that the risk of stillbirth also seems to be influenced by where you live and individual factors and the reasons for this also need to be considered.

Judith Abela, acting Chief Executive at SANDS, the UK’s leading still birth charity has expressed support for a more the affective review process, and ensuring involvement of parents: “Parents perspective of what happened is critical to understanding how care can be improved, and they must be given the opportunity to be involved, with open, respectful and sensitive support provided throughout”.

As a solicitor who acts on behalf of parents who have suffered stillbirth and also children who have suffered severe brain injuries at the time of their birth, I fully support a need for more thorough investigations when these incidents occur so that we can learn from those incidences and hopefully reduce the devastating incidents of stillbirths and brain injury following childbirth in the future.

I await with interest the findings of the full report following completion in 2017.

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