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Sands Midwifery Fellow

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

Sands Midwifery Fellow – Support to improve the quality of local investigations

Margaret Keenan – Sands Midwifery Fellow

Findings from the first Each Baby Counts report shone a light on maternity services, particularly intrapartum care and birth. The report highlighted the variable quality of local reviews and revealed significant variation around what constituted parental involvement.

The role of the Sands Midwifery Fellow, a new role made possible by the generous donation from Sands, the stillbirth and neonatal death charity, is to improve the quality of local investigations following the death or severe brain injury of a term baby as a result of something that happened in labour.

I work with the Each Baby Counts team reviewing and analysing reported Each Baby Counts cases which are highly sensitive. This enables me to look at current practice in units around how investigations are conducted.

As well as working with the Each Baby Counts team I will be working directly with trusts and health boards to support increased parental involvement in the investigation process. This will include visiting units to seek to understand the unit culture particularly around the barriers to high quality reviews, including parental involvement, and through working with clinicians via focus groups.  

The findings will help me in developing appropriate tools and resources for trusts and health boards and to support them to implement them across their organisations.

If you are keen for further support in improving the quality of reviews within your own unit please contact me at


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