Three in every four babies who died or suffered an injury during childbirth may have been avoided if they had received different care, according to a disturbing new report, and when issues have arisen there remain on-going failures to investigate fully or include the family, despite the on-going duty of candour.
We have seen first-hand the incredibly traumatic experiences of parents whose baby has died or been injured during childbirth, only to find it has been caused by errors made by the hospital trust and that lessons have not been learnt from on-going issues that have been identified, from training to equipment.
Shocking Findings of RCOG Report
Each Baby Counts, a new inquiry by the Royal College of Obstetricians and Gynaecologists (RCOG), looked at more than 1,136 stillbirths, neonatal deaths and brain injuries which recently occurred in UK maternity units.
Of these, more than 400 cases were not investigated thoroughly enough for the RCOG to fully assess for the report. The 727 cases which were, revealed hospital staffs knowledge and recognition of interpreting heart-rate patterns (from CTG trace machines) was a significant issue.
The report also revealed parents were invited to be involved in only a third of the local reviews.
What Needs to Happen Next to Improve Maternity Care?
The findings of this report are extremely concerning and will no doubt raise many questions as to what Trusts have done since 2015 to improve the safety of babies and their mothers during child birth.
Around this time last year we saw that a majority of investigations carried out by hospitals branded ‘inadequate’ by the RCOG.
The Each Baby Counts report recommends:
- all low-risk women are assessed on admission in labour to see what foetal monitoring is needed;
- staff get annual training on interpreting baby heart-rate traces (CTGs);
- a senior member of staff must maintain oversight of the activity on the delivery suite;
- all trusts and health boards should inform the parents of any local review taking place and invite them to contribute.
I am instructed by many families in such circumstances, and one such recent example was the Field family who sadly lost Alfie due to failure in not identifying his heart rate problems during labour and ensuring that he was delivered earlier. They have bravely spoken about their experience alongside the report and the on-going issues that need to be addressed.
In cases like these it is essential that lessons are learned, not only by the hospital trust in question but in maternity wards across the UK through sharing experiences.
I represented the Field family at the inquest, at which the coroner confirmed that had Alfie been delivered earlier then he would have survived. Whilst the clinical negligence case was settled the trust also ensured that further equipment was available to monitor babies’ heart rates.
In cases like these it is essential that lessons are learned, not only by the hospital trust in question but in maternity wards across the UK through sharing experiences. This means more robust reviews into what has gone wrong, so that a comprehensive understanding may be rectified and standards improved through being open and honest.
It is vital that parents and external input are taken into account when errors have been made so investigations are not limited internally and that systemic failings that have recurred across the NHS are addressed to prevent such life changing events.
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Tim Deeming is a principal lawyer, specialising in clinical and medical negligence claims at Slater and Gordon Lawyers in Cambridge.