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Each Baby Counts – the RCOG’s plan to reduce avoidable harm to babies in labour

Blog 4 February 2015

From Nicky Lyon, Patient Representative on the Project Advisory Group and Alan Cameron, RCOG Vice President, Clinical Quality.

Nicky Lyon writes…

Nicky LyonThis week the RCOG launches the data collection phase of Each Baby Counts; a ground-breaking project to reduce the number of otherwise healthy babies in the UK that die or are left severely disabled because something goes wrong during labour.

At present between 500 and 800 babies each year die or suffer severe brain damage as a result of incidents occurring during term labour in the UK. My son, Harry, was one of these babies. What should have been one of the happiest days of my life turned into tragedy when Harry was left brain damaged following errors in care during his full-term labour. As a result Harry was left severely disabled, suffering seizures and being fed via a tube. Sadly Harry died aged 18 months as a result of his brain damage. As a family we were left devastated. What is particularly upsetting is that Harry’s death, like many others, could have been avoided.

Along with another bereaved Mum, Michelle Hemmington, I have since set up the Campaign for Safer Births. In speaking to other parents we have found that families often do not feel that learning from such incidents are being shared, and research has shown that the same errors are being repeated across the UK. The Each Baby Counts project has been set up with the aim of gathering information when these tragedies occur, gaining knowledge and providing learning, with the target of reducing the number of babies that die or are severely brain damaged by 50% by 2020. I am very pleased to represent the perspective of women and their families on the Each Baby Counts Independent Advisory Group. I hope you will follow the project’s progress towards its goals on Twitter, or sign up for regular email updates.

Alan Cameron writes…

Alan CameronThe scope of Each Baby Counts is quite specific; focusing on reducing intrapartum stillbirths, early neonatal deaths (deaths within the first week of a baby’s life) and severe brain injuries, that happen as a result of incidents occurring during term labour (37 weeks or over).

Achieving our ambitious target will rely on the commitment of maternity services across the UK to carry out open and honest investigations when these incidents occur, submitting the results of these investigations to us, and then making the improvements that we will recommend further down the line. It is our job, led by the Project Team and Advisory Group, to collect and analyse the data and identify any common themes that emerge. We will then be able to identify best practice and support hospitals to make changes which, we are confident, will reduce and prevent these tragedies from recurring.

This month sees the data collection phase begin which will continue over the next 5 years. Every UK maternity service has been asked to nominate a Lead Reporter, who has received training on how to accurately report cases to us. It will take some time for the data to build up before we can begin analysing it, so at this early stage our priority is making sure it is captured and reported accurately.

For the majority of maternity units there is already a system in place to investigate and report Serious Untoward Incidents (SUIs) like the ones we are focussing on in this project, as well as the local expertise to make sure they are conducted well. But Each Baby Counts will focus resources on making sure that all investigations are conducted thoroughly and uniformly, and that the lessons learned are both acted upon and shared in order to improve the quality of care in labour at a national level.

We already know that the families affected by these tragedies are not always involved in the investigation. In fact sometimes families are not even made aware that an investigation has taken place. It is very clear from the insight that Nicky, Michelle and other patient support organisations have brought to the project team, that not only do families want to be informed of the process and outcome of any review, but they actively want to be involved in it. We are committed to keeping the public involved and up-to-date on how Each Baby Counts progresses. We will continue to use this blog to keep you informed so please look out for further updates.

Sadly, too many individuals and families are passionate about improving things because of their own tragic experience and that’s why this project is happening; to get to a stage where it will be as safe for a baby to be born as it is for a mother to deliver.