Where a reviewer indicates that there is enough information contained in the uploaded local review to assess the care provided, the reviewer is then asked whether different management might have made a difference to the outcome.
In 24% of babies, the reviewers agreed that – based on the information contained in the local review – different management was unlikely to have made a difference to the outcome (Figure 6). In the remaining 556 (76%) instances, at least one of the independent reviewers considered that different management might have made a difference to the outcome.
Figure 6. Proportion of babies for whom different care might have made a difference to the outcome (N=727)
Where a reviewer considers that different care might have made a difference to the outcome, they are asked to indicate what the critical contributory factors were in the care provided. The distribution of these factors for babies born in 2015 is outlined in Figure 7 under the theme in which the factors fall. Note that reviewers are able to select more than one critical contributory factor and the review of care for these 556 babies identified over 3800 critical contributory factors. The average number of critical contributory factors identified for each of the 556 babies was 6 and there were no babies where a single identifiable critical contributory factor could be conclusively identified. The reviewers found that there are multiple and complex interactions between clinical and non-clinical factors which can often be inter-related.
Figure 7. Critical contributory factors identified in babies for whom different care might have prevented the outcome (N=556)
In addition, specialist neonatal reviewers also assessed the neonatal care in the 91 reports where there was sufficient information to classify the neonatal care provided. This analysis found that in 50 (55%) of the 91 reports reviewed, delivering neonatal care in a different manner might have made a difference to the outcome.
Neonatal specialist reviewers often identified critical contributory factors which were not an existing option on the current Each Baby Counts online review pro forma. As a consequence the ‘other’ option under the ‘management of neonatal care’ heading was completed in 54% of instances where the reviewer considered that different management might have made a difference to the outcome. From these, common themes were identified, and a new version of the review pro forma will capture these.
Further information and key recommendations that can be made from the care of babies relating to intrapartum fetal monitoring, individual human factors and lack of nontechnical skills, and neonatal care can be found in the respective chapters of this report.