Of the 1136 babies reported for 2015, the information for 1023 (90%) babies has been fully completed by a Lead Reporter on the Each Baby Counts online reporting system.
There were 113 reports on the system which were started but were not, for a variety of reasons, completed by the Lead Reporter(s) of the relevant trusts/health boards. Of the 1023 completed reports, 969 (95%) had a local review of some kind carried out.
Quality of local reviews
Out of the 969 local reviews which have undergone assessment to determine if enough information has been included in the investigation review to allow an assessment of the care provided, 727 (75%) contained sufficient information in order for the expert reviewers to classify the care provided (Figure 2).
Figure 2. Breakdown of completed investigation reports containing sufficient information to classify the care provided (N=969)
The reasons for the classification of 242 (25%) reviews as containing insufficient information by Each Baby Counts reviewers were as follows:
- no detailed case description – 201 (83% )
- no timeline provided – 189 (78%)
- no specific tool used – 170 (70%)
- other – 153 (63%).
Note that the reviewers could highlight more than one reason why the information contained in the report was considered to be insufficient.
Examples of the ‘other’ reasons include:
- “Unclear whether the policy was followed and which policy/guidelines used.”
- “Lack of information regarding antenatal risk factors.”
- “Slides from perinatal mortality meeting only.”
- “No details of the events, only a short summary available.”
- “This is a supervisory review not an investigation report.”
- “Just a timeline up to delivery, no gases, no description of what happened after delivery. No explanation of why the baby died.”
Although these 242 babies’ reports were considered to contain insufficient information for clinical assessment, the Each Baby Counts team has looked at these reviews in relation to parental and external expert involvement. In 127 (52%) reviews there was no parental involvement in the review. In a further 93 (38%) reviews the parents were made aware of the review and/or informed of the outcome of the review, but in only 22 (9%) reviews were the parents invited to contribute to the review. An external panel member was on the review panel in only 7 (3%) reviews.
Out of the 727 reviews fully completed by midwifery and obstetric reviewers with sufficient information to classify the care, 148 (20%) were assessed as requiring further review by a specialist neonatologist. Of those, 142 (96%) have subsequently been assessed by a neonatologist reviewer trained by Each Baby Counts. In 51 (36%) reviews, the specialist neonatal reviewer felt that the local review did not contain enough information about the neonatal care to enable them to adequately assess the quality of the care provided. The neonatal care for the remaining 91 reviews which contained sufficient information about the neonatal care have been fully assessed by the neonatal expert reviewers to extract the themes and lessons learned.
All local reviews of Each Baby Counts babies should contain sufficient information to determine the quality of the care provided.
Tools and methodologies used in reviews
Out of the 727 local reviews that contained sufficient information, 82% (596 reviews) used a specific tool or methodology to conduct the review. The remaining 18% (131) of reviews were not carried out using any specific process.
Figure 3 shows that, of the local reviews that made use of a specific tool or methodology, the process most commonly used (61%) was Root Cause Analysis. As local investigators may use a range of tools or methodologies in any given review, multiple options could have been checked.
Figure 3. Tools and methodologies used in local reviews containing sufficient information (N=727)
Make-up of local review panels
Results show that 96% of local reviews where the quality was sufficient to judge the care were carried out by a multidisciplinary team (i.e. a panel that contained individuals with expertise from more than one specialty). Although these results are encouraging, the Each Baby Counts team would reiterate that the composition of the panel should ensure that individuals with all the relevant expertise according to the circumstances of the incident are involved.
As expected, midwives and obstetricians were regularly present, but participation from other specialities was lower with senior management involved in 48% and anaesthetists involved in 11% of reviews (Figure 4).
Of the 727 reviews with sufficient information for the reviewers to classify the care provided, 628 concerned babies who were born alive. Neonatal clinicians were involved in reviewing the care of only 429 (68%) of these babies. This should be improved to ensure that expert opinions and recommendations relating to the neonatal care of the baby are included in the local review process.
Figure 4. Contributors to local review panels for reviews containing sufficient information (N=727)