Local investigations into baby deaths have improved, says RCOG

By Julie Griffiths on 13 November 2018 Research Premature Birth Disabilities Newborn

A progress report reveals improvement of local investigations into baby deaths and brain injuries that happened during childbirth.

The latest report from the RCOG’s Each Baby Counts clinical initiative shows there was an increase in the number of completed local investigations into stillbirths, neonatal deaths and severe brain injuries that occurred from incidents during term labour in 2016 across the UK, when compared to 2015.

The quality of reporting improved by 14% from 2015, with more reports containing sufficient information for review. However, the report highlights that the number of incidents where different care might have led to a different outcome still remains too high, with 71% of babies who might have had a different outcome with different care.

The main areas of care in which improvements might have led to a different outcome included a failure of health professionals to identify or act upon relevant risk factors, issues related to monitoring of fetal wellbeing with CTG and blood sampling and individual education or training issues.

Of the nearly 700,000 babies born in 2016, 1123 babies fulfilled the Each Baby Counts criteria. There were 124 stillbirths, 145 babies who died early and 854 babies who sustained severe brain injuries during labour at term.

In almost half (45%) of the affected babies, guidelines and best practice were not followed. Reasons for not following guidelines included gaps in training, lack of recognition of problems, communication issues, heavy workload, staffing levels and local guidelines not being based on best available evidence.

The report makes a number of recommendations including addressing workload issues, an individualised management plan for women during antenatal, labour and postnatal care, and ensuring local guidelines are updated in line with national guidance.

RCM head of quality and standards Mandy Forrester said there are real improvements being made through this project to improve the safety and quality of care for mothers and babies. 

‘This project is clearly making a difference and that is very welcome. However, as the report shows, there is much more that needs to be done,’ she said. 

She added that she is concerned that there are still issues affecting care, such as staff capacity and training and failures to involve the parents. She is also concerned also that in some cases guidelines and best practice were not followed.

‘We need to be doing everything we possibly possible to prevent further tragedies happening, and that is why we support the RCOG’s call for a UK national centre of excellence for maternity care,’ Mandy said.

Read the Each Baby Counts: 2018 progress report here.