Adherence to best practice on fetal monitoring and neonatal care also identified as crucial to improving outcomes
Case studies included at the end of the release
A detailed analysis of all stillbirths, neonatal deaths and brain injuries that occurred during childbirth in 2015 has identified key clinical actions needed to improve the quality of care and prevent future cases, reveals a summary 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 babies who die or are left severely disabled as a result of preventable incidents occurring during term labour (after 37 weeks) by 2020.
The investigation team has now conducted 2,500 expert assessments of the local reviews into the care of 1,136 babies born in the UK in 2015 – 126 who were stillborn, 156 who died within the first seven days after birth and 854 babies who met the eligibility criteria for severe brain injury*.
The reviewers concluded that three quarters of these babies - 76% - might have had a different outcome with different care. This finding was based on 727 babies where the local investigation provided sufficient information to draw conclusions about the quality of care. A quarter of the local investigations were not thorough enough to allow full assessment.
Co-principal investigator, Professor Zarko Alfirevic, consultant obstetrician at Liverpool Women's Hospital, said: “Problems with accurate assessment of fetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting fetal heartrate patterns, have been cited as factors in many of the cases we have investigated.
“This is the first time the Each Baby Counts team has been in a position to identify and share the lessons learned across the whole UK maternity service. However, until every incident is thoroughly investigated and important lessons identified locally, our understanding of the national picture will remain incomplete. The focus of a local investigation should be on finding system-wide solutions for improving the quality of care, rather than actions focusing only on individuals.”
While last year’s interim report made a number of recommendations about how to ensure future investigations are as consistent and effective as possible, this full report of 2015 data goes much further and includes recommendations highlighting critical factors in the care of many of the Each Baby Counts babies that may prevent these incidents in the future.
The recommendations are aimed at doctors and midwives working in maternity units across the UK and centre around:
- Fetal monitoring – formally assessing all low risk women on admission in labour to determine the most appropriate fetal monitoring method; following NICE guidance on when to switch between intermittent and continuous monitoring during labour; ensuring all staff have documented evidence of appropriate annual training
- Neonatal care – paediatric/neonatal teams informed of pertinent risk factors in a timely and consistent manner
- Human factors– understanding ‘situational awareness’ to ensure the safe management of complex clinical decisions; key members of staff maintaining appropriate clinical oversight; seeking a different perspective to support decision making, particularly when staff feel stressed or tired; ensuring everyone understands their roles and responsibilities when managing a complex or unusual situation
Professor Alfirevic continued: “We urge everyone working in maternity care to ensure the report’s recommendations are followed at all times. Trusts and Health Boards have a role to play in supporting their staff to implement the recommendations, ensuring staff tasked with fetal monitoring interpretation receive annual training, promoting the development of non-clinical skills such as situational awareness and providing multi-disciplinary training to support good team working.
“Our next steps are to seek feedback and work with the maternity teams on implementation. To make a real difference, specific implementation tools are needed together with ongoing support for Trusts and Health Boards to embed them into practice. This requires specific skills, dedicated time and significant funding.”
Professor Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists, said: “The Each Baby Counts programme was intended as a ground-breaking, long term inquiry that will deliver improvements to maternity care over time, and we do not waver from this challenge.
“It is a profound tragedy whenever a death, disability or illness of a baby results from incidents during labour. The emotional cost to each family is incalculable and we owe it to them to properly investigate what happened and ensure the individuals and the healthcare Trusts involved take the steps needed to avoid making the same mistakes again.
“Through our detailed analysis of local reviews we are beginning to understand the vast variation in the effort and time that different NHS institutions put into investigating incidents and learning from mistakes in their maternity services. The fact that a quarter of reports are still of such poor quality that we are unable to draw conclusions about the quality of the care provided is unacceptable and must be improved as a matter of urgency.
“Each Baby Counts is a crucial element of the changing safety culture within the NHS. The RCOG and its partners are serious about improving the safety of maternity services but to make this happen we need the full and total commitment from governments across the UK. As an urgent priority, maternity units need to be adequately resourced – without this, Trusts, Health Boards and healthcare professionals will struggle to implement these recommendations.”
For media enquiries and copies of the summary report, please contact the RCOG press office on 020 7772 6773 or email firstname.lastname@example.org
Mel Scott, Somerset
“After previously suffering a miscarriage, I was overjoyed to be pregnant in 2009. After a nervous 12 weeks, I settled into a beautiful, problem free pregnancy.
“At 41 weeks, I thought my waters had broken so my husband, Barry, and I went to hospital. I was admitted to the antenatal ward but a few hours later a CTG showed my baby’s heart beat was dropping so I was rushed in for an emergency caesarean section.
“On August 2, Finley John Scott was born. Sadly he didn't wake up.
“Barry arrived at the hospital to discover that I'd had surgery, we had a son and that he hadn't been able to be resuscitated. Barry spent time with the midwife, bathing and dressing Finley, all of which was captured on video. We were fortunate to be able to stay for three days in the bereavement suite and make treasured memories with our son. We had prints of his hands and feet done, he was blessed, casts were made, we gave him gifts and friends and family visited.
“We later discovered that key opportunities to save Finley were missed. The first CTG was in fact suspicious and there were delays in a doctor seeing me due to the busy labour ward. There were queries over whether a different outcome may have occurred had I had one-to-one care on the labour ward.
“Each Baby Counts is so important. Whilst no one can say that Finley would have survived, having doubts about the path that my labour took is distressing to me. I wish everything that could have been done was done.”
Kym Field, Cambridgeshire
“On 19 December 2015, I went into hospital to be induced as my waters had broken by active labour hadn’t started. Leaving the house, my husband and I we were so full of excitement and anticipation to meet the baby we had waited nine months for.
“As soon as my baby, Alfie, was born, he was handed to paediatric doctors. He was then briefly shown to us before being whisked away. The next morning we were told there was nothing more they could do for our perfect baby boy, who was the image of his father. Details were sparse but we were told he had no brain activity. We had to say goodbye before we even had chance to say hello. It was, to this day, the hardest thing we have ever had to do. Instead of organising a date for family to come and meet our perfect new bundle, we arranged his funeral.
“After three months of going round and round every eventuality in our head, we were told “the root cause of the incident was that Alfie’s CTG trace was misinterpreted during labour”. Our baby’s death was down to a collection of errors and negligence. He was our perfectly healthy boy until a few hours before he was born when he was showing all the signs of struggling but this was simply not interpreted correctly. Many opportunities were missed. Hospital meetings and the inquest passed in a blur. All we wanted was our precious perfect baby in our arms.
“One thing was for sure, we had to do everything we could to ensure no one else found themselves in our situation, or those who did had support in place. After raising £10,000 for charity, we later discovered Each Baby Counts. Finally, someone who acknowledges that mistakes happen and wants to work together to ensure they are learnt from. No family should ever have to go through what we have.”
Notes to editors
*The Each Baby Counts definition of severe brain injury is based on information available within the first 7 days after birth and it is not known how many of these babies will have a significant long-term disability as a result of the injuries sustained during birth.
Of the 800,000 births in the UK, 0.1% of term babies are intrapartum stillbirths, early neonatal deaths and severe brain injuries.
Findings related to full review of all 2015 incidents (first published in the 2016 interim report)
25% of the local reviews did not contain sufficient information to draw conclusions about the quality of care provided.
The Each Baby Counts team analysed in detail 727 thoroughly conducted local reviews:
- Parents were invited to be involved in only 34% of reviews
- External panel members were involved in only 9% of reviews
- Neonatologists were involved in 68% of local review panels of liveborn Each Baby Counts babies
- Where clear actions or recommendations were made in local reviews, 23% were aimed solely at individual members of staff
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.