Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

Maternity services urged to review serious clinical incidents in labour

  • 1 Comment

UK maternity services are being called on to report all cases of intrapartum stillbirth, early neonatal death and severe neonatal brain injury occurring as a result of incidents during term labour.

It forms part of the Royal College of Obstetricians and Gynaecologists’ Each Baby Counts project, a five-year initiative aiming to reduce the number of these events by 50% by 2020.

The project was launched in October 2014 and data collection will begin today.

A crucial part of the project involves bringing together the lessons learned from local investigations in order to improve the quality of care in labour at a national level, said the RCOG.

“We hope that all maternity providers will show their support for this project”

Alan Cameron

Stillbirth rates in the UK remain high and current estimates suggest 500 to 800 babies a year die or are left severely disabled because of potentially avoidable harm in labour.

Rigorous investigations into such cases should already be carried out as a matter of course in every maternity unit, following guidance issued by the RCOG in 2009. But the college now also wants the results submitted to it via a secure, online platform.

The results of these reviews will be analysed in order to identify avoidable factors and develop action plans suitable for local implementation.

By identifying common themes across the country which relate to these events, the RCOG will also be able to advocate for national change, where appropriate, as well as encourage local service improvements.

The majority of trusts and health boards have now nominated a lead reporter and have received training on how to report eligible cases, said the college.

“Frustratingly not all deaths are reviewed rigorously to ensure lessons are learned when mistakes do happen”

Charlotte Bevan

Professor Alan Cameron, RCOG vice president for clinical quality and co-principal investigator for Each Baby Counts, said: “We hope all maternity providers will show their support for this project and engage in reporting and learning from these tragic incidents.

“There can be little justification for neglecting to undertake reviews when the outcome for parents is as devastating as the loss of a child, or a child born with a severe disability,” he said.

“The collection of data is a key part of the project and its success depends on high quality information being submitted for national analysis,” he added.

Charlotte Bevan, senior research and prevention adviser at the stillbirth and neonatal death charity Sands, said it was an “important project”.

“Standards of care can vary considerably across the country and frustratingly not all deaths are reviewed rigorously to ensure lessons are learned when mistakes do happen,” she said.

  • 1 Comment

Readers' comments (1)

  • It will be good to have analysis by "outside" specialists. Efforts are made during internal investigations to remain objective and thorough, but there is always a tendency towards protection of colleagues, even though many do their best to resist it.

    Unsuitable or offensive? Report this comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.

Related Jobs