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Recommendations – neonatal involvement in reviews



All reviews of liveborn Each Baby Counts babies must involve neonatologists/neonatal nurses.


Neonatal reviewers indicated that the information contained in the local review relating to the neonatal care of the baby could have been more comprehensive. In over one-third of local reviews assessed by specialist neonatal reviewers, 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 scrutiny of initial neonatal management and subsequent neonatal care needs to improve, particularly with respect to the timelines recorded during resuscitation.


Detail on whether local guidelines were followed should be included. A final diagnosis for the baby should ideally be included together, where possible, with clinical evidence to support the final diagnosis, e.g. MRI results and/or a postmortem report in the event of an early neonatal death.


Even when the need for improvements in obstetric care has been identified, there may be further improvements in neonatal care that a specialist neonatal reviewer may identify. This was a weakness in the original Each Baby Counts methodology which project team has sought to rectify.


Each Baby Counts action

All babies who are born alive and reported to Each Baby Counts will in future be reviewed by midwifery, obstetric and neonatal reviewers.


If a neonatal review of the care provided to a stillborn baby is deemed necessary once the initial Each Baby Counts review has been undertaken by an obstetrician and a midwife, this will be arranged. The neonatal review of all liveborn Each Baby Counts babies is planned to begin from January 2018.


External involvement in reviews

Only 9% of panels included an external expert (Figure 4, previous page). Where external panel members were present, these were mostly midwives and obstetricians, but they also included the Care Quality Commission, commissioner representatives and coroners.



All local reviews must have the involvement of an external panel member.


Parental involvement in reviews

Parental involvement in reviews was inconsistent and requires improvement. In 19% of local reviews, the parents were neither involved nor made aware that a review was taking place. In just over one-third (34%) of instances, the parents were invited to contribute to the review if they wished to (Figure 5).



All trusts and health boards should inform the parents of any local review taking place and invite them to contribute in accordance with their wishes.


It should be noted that there are a number of different approaches to involving parents in reviews and a personalised approach should be undertaken. We note that attendance at local investigation meetings in person is not necessarily the most appropriate way to involve parents in reviews. The RCOG acknowledge that there is currently a lack of evidence about how best to involve parents and would welcome the results of work that is currently underway to address this lack of evidence.


Sands, the stillbirth and neonatal death charity, has published ten principles that detail what Sands consider to be the key elements of high-quality bereavement care.[i] These principles include the involvement of parents and this should be applied to all local reviews into the care of babies eligible for Each Baby Counts.


EBC 2015 Report figure 5

Figure 5. Parental involvement in local reviews containing sufficient information (N=727)




[i] Sands. Principles of Bereavement Care [].