Investigations Into Stillbirths And Neonatal Deaths Are 'Inadequate', New Report Suggests

'Improvements are needed as a matter of urgency.'

10/06/2016 10:48

More than half of investigations into stillbirths and neonatal deaths following full-term labour are insufficient, according to the Royal College of Obstetricians and Gynaecologists (RCOG).

Out of 204 investigations, 56% of reviews were deemed “inadequate”, a new report has shown. 

Hospitals are therefore not learning from potentially avoidable deaths or serious injuries sustained by babies during labour.

The report is the first in a series from data collected as part of RCOG’s Each Baby Counts initiative, which aims to halve the number of incidents of stillbirth, neonatal death and severe brain injury during full-term labour by 2020.

"It is clear that we need more robust and comprehensive reviews, which are led by multidisciplinary teams and include parental and external expert input," said Professor Alan Cameron, RCOG’s vice president for clinical quality and co-principal investigator for Each Baby Counts, according to PA.

“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."

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Each Baby Counts reviewers assessed 204 investigations. They found that 27% of the reviews were “poor quality”. And 39% of the remaining reviews, (or 29% of all reviews), did not include any actions to improve care.

Overall, 56% were "inadequate". 

The report found that only a quarter of parents were invited to contribute to the investigation into the death or injury of their baby. 

Meanwhile one in four parents were not even told that a review was taking place.

"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 the poor quality of reviews," Cameron continued.

"Only by ensuring that local investigations are conducted thoroughly with parental and external input can we identify where systems need to be improved."

The RCOG has called for more robust reviews into these cases, particularly for more parental input to be included in the investigations. 

"These important findings add to the wealth of evidence that investigations into baby deaths are not of an acceptable standard," Judith Abela, acting chief executive of stillbirth and neonatal death charity Sands said.

"A robust, thorough review process must be implemented without delay, and resourced adequately.

“Crucially, parents must be given the opportunity to input into the investigation into the death of their baby and the outcomes must be shared with them.

"It’s not about apportioning blame, rather ensuring everything possible is done to understand what happened so that we can learn from deaths and prevent future tragedies."

Nicky Lyon, parent representative on the Each Baby Counts advisory group and co-founder of the Campaign for Safer Births, said, according to PA: “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.

“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.”

Louise Silverton, director for midwifery at the Royal College of Midwives, added: “This report clearly shows that improvements in the investigation process are needed.

“Each one of these statistics is a tragic event, and means terrible loss and suffering for the parents. We must do all we can to reduce the chances of these occurring.

"This report shows that this is not the case and improvements are needed as a matter of urgency."

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