More robust and comprehensive local reviews are urgently needed to ensure lessons can be learnt and improvements made
The quality of local investigations into cases of stillbirth, early neonatal death and severe brain injury occurring as a result of incidents during term labour must improve, highlights the first annual report from the Royal College of Obstetricians and Gynaecologists’ (RCOG) Each Baby Counts initiative.
Each Baby Counts is a national quality improvement programme, launched in October 2014, aiming to halve the number of these tragic events by 2020. This project will bring together the lessons learned from a review of all local investigations in order to improve the quality of care in labour across the UK.
The interim data from 2015 reveal that 921 babies were reported to the Each Baby Counts programme. Of these, 654 (71%) were classified as having severe brain injuries, and there were 147 (16%) early neonatal deaths and 119 (13%) stillbirths that occurred during term labour.
Of the 610 reports which have been completed 599 (98%) have had a local investigation of some kind and 204 have been assessed by Each Baby Counts reviewers to date. However, 27% of these were classified poor quality as they did not contain sufficient information for the care to be classified. Of those that passed the initial quality checks, 39% contained no actions to improve care or only made recommendations which were solely focussed on individual actions.
Although 96% of reviews were made up of multidisciplinary teams, including midwives and obstetricians, only 62% included a neonatologist, 44% included a member of the senior management team and 10% an anaesthetist. Only 7% of local review panels included an external expert.
In a quarter of local reviews, the parents were not made aware that an investigation was taking place. In 47% of the reviews, parents were made aware that an investigation was taking place and were informed of its outcomes, but in only 28% were parents invited to contribute to the investigation.
Professor Alan Cameron, RCOG Vice President for Clinical Quality and co-Principal Investigator for Each Baby Counts, said:
“This report shows that although some trusts are conducting reviews very well, it is clear that we need more robust and comprehensive reviews, which are led by multidisciplinary teams and include parental and external expert input. Additionally, we need to move to a more standardised national approach for carrying out these investigations to improve future care. The focus of a local investigation should also be on finding system-wide mechanisms for improving the quality of care, rather than individual actions.
“Stillbirth rates in the UK remain high and our current data indicate that nearly 1,000 babies a year die or are left severely disabled because of potentially avoidable harm in labour. The emotional cost of these events is immeasurable and each case of disability costs the NHS around £7million in compensation to pay for the complex, lifelong support these children need – this equates to nearly half of the NHS’ litigation budget.
“Currently, there is a lack of consistency in the way local investigations are conducted. When the outcome for parents is the devastating loss of a baby, or a baby born with a severe brain injury, there can be little justification for poor quality reviews. Only by ensuring that local investigations are conducted thoroughly with parental and external input, can we identify where systems need to be improved. Once every baby affected has their care reviewed robustly we can begin to understand the causes of these tragedies.”
Miss Kate Harding, Consultant Obstetrician and an external reviewer for maternal death investigations, said:
“Having an external expert as part of a local review process is a vital way of truly learning from mistakes that happen in healthcare. Every time a maternal death occurs in our region, an external expert will participate in a local investigation. This allows for an unbiased perspective and an ability to review events against national standards, focusing on system-wide approaches to improving services, rather than identifying an individual who may need further training. We now need to see this process expanded to include investigations into stillbirths, early neonatal deaths and brain injuries.”
Ms Judith Abela, Acting Chief Executive at Sands, the stillbirth and neonatal death charity, said:
“The death of a baby has a lifelong impact on families and Sands supports hundreds of parents every year whose baby has died before, during or shortly after birth. Many believe their baby’s death was not inevitable and opportunities were missed to save their child.
“We have been calling for a robust and effective review process for some time, including parental involvement in local investigations. Parents’ perspective of what happened is critical to understanding how care can be improved and they must be given the opportunity to be involved, with open, respectful and sensitive support provided throughout.”
Ms Nicky Lyon, parent representative on the Each Baby Counts Advisory Group and co-founder of the Campaign for Safer Births said:
“Our son Harry suffered profound brain damage during term labour. After a difficult life of tube feeding, constant sickness, fits and discomfort, our son died of a chest infection aged 18 months. As a family we have been left devastated at the loss of our beautiful boy.
“In the days following Harry’s birth we asked what had gone wrong, but we were ignored. It was only after submitting a formal complaint that we learnt that an investigation was already underway. It’s hard to describe how upset, confused and angry we were – the poor communication and secrecy made a terrible situation so much worse.
“Patients and their families should always be at the heart of a review, and being included in the process would have made such a difference to our family.”
Ben Gummer, Health Minister, said:
“These findings are unacceptable. We expect the NHS to review and learn from every tragic case which is why we are investing in a new system to support staff to do this and help ensure far fewer families have to go through this heartache.
“Our ambition is to make the NHS one of the safest places in the world to have a baby and halve the number of stillbirths and neonatal deaths by 2030.”
The next phase of the Each Baby Counts programme involves undertaking a structured review of each case that occurred in 2015, identifying the themes that emerged and developing an action plan on how lessons can be learned.
For media enquiries and copies of the full report, please contact the RCOG press office on 020 7772 6444 or email firstname.lastname@example.org
Of the 800,000 births in the UK, 0.1% of babies are intrapartum stillbirths, early neonatal deaths and severe brain injuries.
Our definition of severe brain injury is based on information available within the first 7 days of life. We do not yet know how many of these babies will have a significant long-term disability as a result of their injuries sustained during childbirth. However, 96% of these babies were actively cooled, an intensive intervention requiring sedation and admission to the special care unit, this reflects the serious condition these babies were in at birth.
Case studies are available on request (tbc).
Each Baby Counts is the RCOG’s national quality improvement initiative to reduce by 50% the number of babies who die or are left severely disabled as a result of incidents occurring during term labour by 2020. The project has had a 100% participation rate with UK NHS Hospital Trusts.
The Royal College of Obstetricians and Gynaecologists (RCOG) is a medical charity that champions the provision of high quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision.
 The reporting window for 2015 is not yet closed and case ascertainment based on other sources of national data is still underway. Details of case eligibility are included in the report.