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Foreword from Edward Morris, RCOG President

Each Baby Counts launched in 2014 with a clear ambition to reduce stillbirths, neonatal deaths and brain injuries as a result of incidents occurring during term labour. This was an enormous undertaking in which I am both professionally and personally invested. Professionally, because I have been involved in this project since its first report, and personally, because I know that each serious incident has a profound and life-changing effect on so many people.

This will be our last progress report as the important work of investigation and reporting will be the responsibility of the Healthcare Safety Investigation Branch in England. In addition to ensuring that this work continues, the UK Government remains committed to its national ambition to halve the rates of stillbirths, neonatal and maternal deaths and intrapartum brain injuries by 2025.

The ethos of the Each Baby Counts programme will therefore remain a priority for the healthcare system. However, as a College we recognise that the recent investigations at individual trusts, and the publication of the interim Ockenden report, must be a watershed moment for maternity services. The entire health system must recommit itself to challenging safety issues head on.

Each Baby Counts very effectively opened a discussion on what had been a very difficult issue. But it is now imperative that the health system shifts its focus from counting to acting. We have unfortunately not seen the impact in the annual figures that we had hoped. And although more and more parents are now involved in investigations, ultimately we need to make sure that no family has to experience the pain of an outcome that, with the right care, might have been different.

This final report includes qualitative feedback from individuals across various organisations involved in improving maternity safety. This will, I hope, be useful in designing future programmes of work, and helpfully reflects my own feelings about how we move forward. From now, our progress should be judged by the practical actions we can take to implement the recommendations of this project, and that is what we intend to do. We are working to improve leadership and culture, to implement practical changes which will improve electronic fetal heart monitoring, and to ensure our workforce is well supplied with the appropriate expertise across all maternity units.

I would like to thank the Each Baby Counts team at the College for their dedication to this project over the years, as well as our investigators, and our co-principal investigators Zarko Alfirevic and Alan Cameron. A huge thanks also to the Each Baby Counts reviewers and the Independent Advisory Group for providing strategic direction and governance of the activities of the programme. This project could not have been successful without the support and contribution from our lead reporters across NHS trusts and health boards as well as the healthcare professionals who have engaged openly with this process.

Most of all, I would like to thank the families who have supported this project. All of them have suffered immeasurably and, in the face of their suffering, have worked tirelessly to make services safer for other people.

Edward Morris MD FRCOG
President, Royal College of Obstetricians and Gynaecologists