Investigations into baby deaths are inadequate

A new “Each Baby Counts” report released today reveals that hospital investigations into babies who die or who are severely brain damaged during labour are inadequate and affect ongoing learning and improvement in care.

Each Baby Counts is a quality improvement programme led by the Royal College of Obstetricians and Gynaecologists. Its primary aim is to half the number of babies who die or who are left severely disabled as a direct result of harmful incidents during term labour, by 2020. The project works to bring together a national picture of the situation so that lessons can be learned and improvements made.

The report’s key findings have highlighted the importance for every baby eligible for ‘Each Baby Counts’ to be given a full, robust and multidisciplinary review and that parents should be aware and invited to participate. It has also been advised that review teams recognise the benefit of an external member in the review to bring a different perspective to the process. The focus of these reviews should be about finding systematic rather than individual recommendations to improve care. Lastly, when launched, the standardised perinatal mortality review tool should be utilised.

The main concern identified in the report, in addition to the concerning number of babies affected, is the conduct of hospital review investigations. Of the 599 local reviews conducted, only 52% of these utilised a specific method to conduct a review.

Whilst 96% of reviews were conducted by a multidisciplinary team, the report encourages a more diverse range of professionals to be included in hospital reviews – for example, only 62% involved a neonatologist, and only 44% included a member of the senior management team. One key aspect of the report’s findings was a lack of external input in the review process, with only 7% involving an external expert.

Another key finding related to parental involvement. In 25% of cases, parents were not informed that a review was taking place. In 47% of reviews, parents were aware but not invited to participate, and in only 28% of reviews were parents invited to contribute evidence.

As part of the project’s work, the Each Baby Counts team has started conducting structured evaluations of local hospital reviews, and are working to ascertain the vital elements of a good quality review. These include a detailed history and timeline of events, and use of a structured tool to conduct the review. By reviewing cases comprehensively, health care professionals and maternity services can work to improve care. However, in the evaluations already conducted, 39% were of good quality, yet made no recommendations for improvement in care, or only focused solely on an individual staff member.

Whilst there are other projects looking at different aspects of stillbirth and neonatal deaths, this project has focused on babies who die during labour at 37 weeks or over (intrapartum stillbirths), early neonatal death (i.e. in the first week of life) and those who have been starved of oxygen at birth resulting in a brain injury identified in the first seven days of life.

Out of 800,000 births in the UK during 2015, 921 babies met the above criteria for the Each Baby Counts report. The report has identified the following:

13% (119 babies) were classed as Intrapartum Stillbirth

16% (147 babies) were classed as Early Neonatal Deaths

71% (655 babies) suffered severe brain injuries as a result of incidents during labour

A final report for 2015 is expected in Summer 2017, which will also contain early 2016 data.

You can read the full report here.