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Royal Cornwall Hospital

Below is one of the case studies written by contributors to the Each Baby Counts project.

Royal Cornwall Hospital

Karen Stoyles, EBC Lead Reporter (Antenatal Ward Sister and Bereavement Midwife)
Kate Putman, EBC Lead Reporter (Risk Management Midwife)

We work at the Royal Cornwall where we have approximately 4300 deliveries per year. Since the start of Each Baby Counts we have reported 8 cases via the online system. We have not divided the cases between the maternity and neonatal teams, but decided to approach it as a whole to ensure that cases were not missed. Karen was identified as the lead reporter due to her role as the bereavement midwife; however, this initially meant that there was delay in identifying some of the live cases. In response to this we have improved our reporting system by educating all the delivery suite coordinators and identifying a Neonatal Nurse who links with Karen.

We review our cases at weekly Risk Management Meetings and learning outcomes are recorded on the Database and fedback to staff via the Risk Management Newsletter. Stillbirths and Neonatal deaths are reviewed at the monthly perinatal review meeting. This project has highlighted that quality of care could be further improved by increased feedback both to staff and parents. We are exploring effective ways to do this and would like to hear how other Trusts ensure that learning is shared whilst maintaining an environment where staff feel able to openly discuss cases.

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