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‘Inadequate’ NHS Investigations Risk Further Baby Deaths

‘Inadequate’ NHS Investigations Risk Further Baby Deaths

Many hospitals are not learning from potentially avoidable deaths or serious injuries of babies during labour, according to a new report.

More than 200 cases have been assessed so far by the Royal College of Obstetricians and Gynaecologists (RCOG), which branded half of the investigations carried out by hospitals as ‘inadequate.’

In the majority of cases parents were not asked for their input, with many unaware that a review had even taken place.

Last year 921 babies were born in UK hospitals where mistakes were made in the final stages of labour, leading to death or serious brain injury.

Professor Alan Cameron, RCOG's vice president for clinical quality, said: “It is clear that we need more robust and comprehensive reviews, which are led by multidisciplinary teams and include parental and external expert input.

“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.

“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.

“Only by ensuring that local investigations are conducted thoroughly with parental and external input can we identify where systems need to be improved. Once every baby affected has their care reviewed robustly we can begin to understand the causes of these tragedies.”

The report is the first in a series from data collected as part of RCOG's Each Baby Counts initiative by 2020.

The UK-wide quality improvement programme aims to halve the number of incidents of stillbirth, neonatal death and severe brain injury during full-term labour - when a woman is at least 37 weeks pregnant when going into labour.

Stillbirth and neonatal death charity SANDS is calling for a ‘robust’ review of practices – including making sure parents are included in any investigation.

In response to the report Elizabeth Duff, senior policy advisor at the National Childbirth Trust, said: “NCT supports the call from SANDS for robust and consistent practice in reviews that promotes quality of care across the whole healthcare system.

“It is extremely worrying that so many investigations into serious maternity incidents did not involve the family. Parents must be given the opportunity to contribute to these reviews if they wish to do so, and supported throughout. This may help the grieving process of the parents and their understanding of the need for more tailored care in a later pregnancy.”

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