The Royal College of Obstetricians' "Each Baby Counts" initiative has just produced its latest update report dated November 2018 looking at babies born in 2016. Their aim is to halve the number of babies who die or are left severely disabled by 2020 by reviewing incidents and then advising on how to improve standards.
Their latest update looks at babies born in 2016. They have reported that, of the nearly 700,000 babies born in 2016, 1,123 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 a staggering 71% of these cases - nearly 800 babies - the affected babies might have had a different outcome if they had received the right maternity care.
The "Each Baby Counts" body relies on hospitals and maternity units reporting cases to them with enough information to enable them to review the care as they do not review the hospital records.
It is unthinkable that you would go through the experience of a stillbirth or have a severely injured baby and the hospital begins an investigation into the care but does not involve you or in some cases does not even tell you that an investigation is being done. But this is indeed what happens in a large number of cases.
The "Each Baby Counts" report confirms that in almost a quarter of instances parents were not involved in, or even made aware of, reviews taking place.This fits with our experience and also the conclusions of a report by NHS Resolution (the NHS legal body) in 2017 on Five Years of Cerebral Palsy Claims, that the quality of serious incident investigations was poor and 60% of families were not involved in them.
I am pleased to see that the Report recommends that all trusts and health boards should inform the parents of any local review taking place and should invite them to contribute in accordance with their wishes.
Maternity units are also now required to follow the Early Notification Scheme which involves reporting any potential brain injury to the ENS within 30 days. Familiar themes appear in the contributory factors to injuries, such as errors in fetal heart rate monitoring and inadequacies in staff training. The "Each Baby Counts" report identifies an average of seven critical contributory factors per incident which led to a poor outcome. They include 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 recommends addressing hospital workload issues and improving education and training. There needs to be sufficient government funding to enable proper staffing levels which allow staff time off to attend essential training as well as funding the cost of the training itself. Baby Lifeline continues to push the government to address this gap in training and funds should also be provided to enable the RCOG to push ahead with its proposal for a UK national centre of excellence for maternity care.
Gill Edwards is a member of the Multi-Professional Advisory Panel of the mother and baby charity Baby Lifeline. She is a Partner and clinical negligence solicitor with Potter Rees Dolan. Should you have any queries about clinical negligence issues, in particular birth injuries, and wish to speak with Gill or any other member of the team please contact us on 0161 237 5888.