Skip to main content

Key messages

Research or audit activity should be commissioned to further investigate ‘therapeutic creep’ and how this might account for a lack of change in the Each Baby Counts numbers over time.

A structured and consistent approach to recording local reviews should be established, which ensures that all staff understand and capture the key information that will allow the review to contribute to second-order learning across the maternity and neonatal landscape.

7% is still too high for the proportion of parents not informed about a review; informing and engaging parents continues to be a challenge that needs to be addressed in all future work streams.

It is vital that maternity safety remains on the map for the long term and that high-quality investigations are carried out into these events.