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Neonatal death investigations ‘must improve’

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Over a quarter of local investigations into stillbirths, neonatal deaths and severe brain injuries are “not good enough”, according to the first national review into the area.

Investigations into such cases occurring as a result of incidents during term labour must improve, said the Royal College of Obstetricians and Gynaecologists.

“It is clear that we need more robust and comprehensive reviews”

Alan Cameron

More robust and comprehensive local reviews are urgently needed to ensure lessons can be learnt and improvements made, it said in its first annual report from its Each Baby Counts initiative.

Each Baby Counts is a national quality improvement programme, launched in October 2014, aiming to halve the number of stillbirths, neonatal deaths and severe brain injuries by 2020. The project has had a 100% participation rate with UK NHS Hospital Trusts.

Interim data from 2015 revealed that 921 babies were reported to the programme. Of these, 71% were classified as having severe brain injuries, 16% were early neonatal deaths and 13% stillbirths that occurred during term labour.

Of the 204 reports assessed so far by Each Baby Counts reviewers, 27% were classified as poor quality because they did not contain sufficient information for the care to be rated.

Of those that passed the initial quality checks, 39% contained no actions to improve care or only made recommendations which were solely focused on individual actions.

“The RCM would support a move to a more standardised approach to investigations”

Louise Silverton

In a quarter of local reviews, the parents were not made aware that an investigation was taking place and in only 28% of the others were parents invited to contribute to the investigation.

Professor Alan Cameron, RCOG vice president for clinical quality and co-principal investigator for Each Baby Counts, said: “Although some trusts are conducting reviews very well, it is clear that we need more robust and comprehensive reviews, which are led by multi-disciplinary teams and include parental and external expert input.

“Additionally, we need to move to a more standardised national approach for carrying out these investigations to improve future care,” he said. “The focus of a local investigation should also be on finding system-wide mechanisms for improving the quality of care, rather than individual actions.”

Professor Cameron noted that stillbirth rates in the UK remained high and nearly 1,000 babies a year died or were left severely disabled because of potentially avoidable harm during labour.

Royal College of Midwives

Quarter of stillbirth investigations ‘not good enough’

Louise Silverton

“Once every baby affected has their care reviewed robustly we can begin to understand the causes of these tragedies,” he added.

Louise Silverton, director for midwifery at the Royal College of Midwives, said: “This report clearly shows that improvements in the investigation process are needed.

“It is only through thorough investigation and implementation of recommendations that lessons can be learned from these tragic events,” she said. “We must do everything possible to prevent them, and improve care and safety.

“The RCM would support a move to a more standardised approach to investigations. All should be done to the same high standards,” she said. “Parental involvement should be the norm.

She added: “We would also agree that too often the focus is on individual actions. All healthcare professionals must of course be rigorous in their practice.

“However, they are often working in systems that do not support best practice, and the safest and highest quality care as well as they should,” said Ms Silverton.

“These findings are unacceptable”

Ben Gummer

Judith Abela, acting chief executive of the charity Sands, said: “We have been calling for a robust and effective review process for some time, including parental involvement in local investigations. Parents’ perspective of what happened is critical to understanding how care can be improved.”

Health minister Ben Gummer said the report’s findings were “unacceptable”.

“We expect the NHS to review and learn from every tragic case, which is why we are investing in a new system to support staff to do this and help ensure far fewer families have to go through this heartache,” he said.

“Our ambition is to make the NHS one of the safest places in the world to have a baby and halve the number of stillbirths and neonatal deaths by 2030,” he said

The next phase of the Each Baby Counts programme involves undertaking a structured review of each case that occurred in 2015, identifying the themes that emerged and developing an action plan on how lessons can be learned.

Of the 800,000 births in the UK, 0.1% of babies are intrapartum stillbirths, early neonatal deaths and severe brain injuries.


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Readers' comments (1)

  • It is strange that the aim is to 'make the NHS one of the safest places to give birth', whilst closing maternity and neonatal units across the country, and having so few maternity beds that mothers are not admitted until they are practically pushing and are pressurised to go home within a few hours.. Adding to the problems is the increasing number of older mothers and multiple births (mainly from IVF treatment). Childbirth cannot be had on the cheap, more money needs to be ploughed in now to ensure safety at the very beginning of the journey of life.

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