Each Baby Counts - 'we're not learning from mistakes'

Over a quarter of local investigations into stillbirths, neonatal deaths and severe brain injuries are not good enough, says RCOG report

Hospitals are not learning from stillbirths and neonatal deaths, a new report from RCOG says. And parents are very often not included in the review processes.

The quality of local investigations into cases of stillbirth, early neonatal death and severe brain injury occurring as a result of incidents during term labour must improve, highlights the first annual report from the Royal College of Obstetricians and Gynaecologists’ (RCOG) Each Baby Counts initiative.

The report is the first from the RCOG Each Baby Counts initiative, a national programme that aims to halve the number of stillbirths, neonatal deaths and severe brain injuries that occur during full-term labour, by 2020.

This project will bring together the lessons learned from local investigations into these tragic cases to improve the quality of care in labour across the UK.

Each Baby Counts reviewers have been assessing the investigations and have found that 27% were "poor quality". And that 29% of all reviews did not include any actions to improve care. In total, 56% of reviews were "inadequate", the College said.

In 25% of local reviews, the parents were not told an investigation was happening at all. In 47%, parents were made aware that an investigation was taking place and were told of the outcomes, but in only 28% of the reviews were parents invited to contribute.

Jane Brewin, CEO of Tommy's, said: 'It is unacceptable that a baby dies because midwives or obstetricians fail to do their job as they should. There needs to be a transparent and open review process of every death and a cause should be given for each. Whilst we continue to allow these incidents to be brushed under the carpet the NHS fails parents and their children – the NHS needs to do so much better and needs to operate at the standard of the best. There are examples of excellent practice such as at St Mary’s Hospital in Manchester where the Tommy’s stillbirth research centre is based which has shown a big reduction in their stillbirth rate.

'It’s reassuring to know that the RCOG are committed to tackling poor practice. The profession's ability to criticise themselves and point out their own shortcomings is to be applauded – but of course what parents want is for them to fix the problem and we look forward to seeing their plan to do just that. Parents need to have confidence that they will receive the best possible treatment wherever they live and whenever they access services.'

Professor Alan Cameron, RCOG Vice President for Clinical Quality and co-Principal Investigator for Each Baby Counts, said:

“This report shows that although some trusts are conducting reviews very well, it is clear that we need more robust and comprehensive reviews, which are led by multidisciplinary 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. The focus of a local investigation should also be on finding system-wide mechanisms for improving the quality of care, rather than individual actions.

“Stillbirth rates in the UK remain high and our current data indicate that nearly 1,000 babies a year die or are left severely disabled because of potentially avoidable harm in labour. The emotional cost of these events is immeasurable and each case of disability costs the NHS around £7million in compensation to pay for the complex, lifelong support these children need – this equates to nearly half of the NHS’ litigation budget.

“Currently, there is a lack of consistency in the way local investigations are conducted. 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 poor quality reviews. Only by ensuring that local investigations are conducted thoroughly with parental and external input, can we identify where systems need to be improved.  Once every baby affected has their care reviewed robustly we can begin to understand the causes of these tragedies.”

Ms Nicky Lyon, parent representative on the Each Baby Counts Advisory Group and co-founder of the Campaign for Safer Births said:

“Our son Harry suffered profound brain damage during term labour. After a difficult life of tube feeding, constant sickness, fits and discomfort, our son died of a chest infection aged 18 months. As a family we have been left devastated at the loss of our beautiful boy.

“In the days following Harry’s birth we asked what had gone wrong, but we were ignored. It was only after submitting a formal complaint that we learnt that an investigation was already underway. It’s hard to describe how upset, confused and angry we were – the poor communication and secrecy made a terrible situation so much worse.

“Patients and their families should always be at the heart of a review, and being included in the process would have made such a difference to our family.”

Ben Gummer, Health Minister, said:

“These findings are 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. 

“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.” 

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.

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