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Analysis of local reviews

The information for 1093 (95%) of the 1145 babies reported for 2018 was fully completed by a lead reporter on the Each Baby Counts online reporting system.

The other 52 reports on the system were started but were not completed by the lead reporter(s) of the relevant trusts/health boards. Of the 1093 completed reports, 1070 (98%) had undergone and completed a local review process.

Local reviews containing sufficient information to classify the care provided

Overall, 687 (89%) of the 774 local reviews that progressed to assessment contained sufficient information for the expert reviewers to classify the care provided (Figure 3).

Previous Each Baby Counts progress reports have shown a steady increase each year in the proportion of local reviews that contained sufficient information, with 75% for 2015, 89% for 2016 and 95% for 2017. However, for 2018 there was a reduction in this proportion, which was directly attributable to the three-month project pause due to COVID-19.

Figure 3: Proportion of completed investigation reports containing sufficient information to classify the care provided (N = 774)

Figure 3: Proportion of completed investigation reports containing sufficient information to classify the care provided (N = 774)

Neonatal cases containing sufficient information to classify the care provided

For babies born in 2018, 512 reviews were assessed by Each Baby Counts neonatal reviewers to assess the care of liveborn babies or those undergoing resuscitation.

Of these reports, 319 (62%) were assessed as containing sufficient information specifically about the neonatal care provided (Figure 4). This was substantially lower than the 89% proportion of reports containing sufficient information about overall care.

Figure 4: Proportion of investigation reports assessed by neonatal specialists that contained sufficient neonatal information to classify the neonatal care provided (N = 512)

Figure 4

Download the PDF (2.9mb) see the full report, including sections on:

  • Make-up of local review panels (Figure 5)
  • Tools and methodologies used in reviews (Figures 6 and 7)
  • Quality of reviews (Figure 8)

Parental involvement in reviews

The level of parental involvement in local reviews is encouraging, with 70% of parents invited to contribute to the review in 2018 (Figure 9), compared with 50% in 2017 and 41% in 2016.

Figure 9: Parental Involvement in local reviews containing sufficient information (N = 687)

Figure 9: Parental Involvement in local reviews containing sufficient information (N = 687)

This increase is mirrored in the PMRT annual report, which identified that, for the period March 2019 to February 2020, parents were told the review was taking place in 84% of them, and 84% of reviews sought the parents’ perspective; these compare with 75% and 73% respectively in the previous reporting period of January 2018 to February 2019.

A possible contributory factor in this increase may be the fact that HSIB was rolled out in England over the course of 2018 to provide an external investigation of babies who met Each Baby Counts criteria. HSIB approaches parents and receives their consent to undertake its investigations, and it updates families throughout the investigation process. All families are invited to contribute to the HSIB review, with about 90% of families agreeing to participate. The HSIB review replaces the local review process, with the investigations being conducted in collaboration with the local units and the parents.

It should also be noted that in 7% of cases in 2018 parents were not involved in the local review process. This is a reduction from 17% in 2017 but is still an unacceptable proportion – ideally, parents will always be involved in the review. Informing and engaging parents continues to be a challenge that needs to be addressed for future work streams.

As discussed in previous reports, there are a number of different approaches that can be applied to invite parents to contribute to local reviews. Sands, the stillbirth and neonatal death charity, has information packs to help healthcare professionals engage with parents during the local review process, and these resources can be adapted in cases of therapeutically cooled babies. PMRT and HSIB have also published work in this area.

It is imperative that parents are made aware of the review process and that they are invited to give input and submit their thoughts. Inviting parents’ and their families’ contributions facilitates the local review process leading to a flow of information and promotes transparency in the process. This will ensure that questions and concerns can be raised by all parties and subsequently addressed.