Many baby deaths 'could have been avoided'

21st June 2017 – More than three-quarters of full-term   newborn babies who die or are left with brain damage could have survived or avoided disability if they had received better care, a report has concluded.

The findings are based on a detailed analysis of all stillbirths, neonatal deaths and brain injuries that occurred during childbirth in the UK in 2015.

One charity has described the findings as "shocking".

Each baby counts

The Each Baby Counts review was carried out by the Royal College of Obstetricians and Gynaecologists (RCOG).

It examined the care of 1,136 babies born in the UK in 2015 who died or sustained brain injuries during childbirth. Of these:

• 126 were stillborn
• 156 died within the first 7 days after birth
• 854 babies had severe brain injuries

The reviewers conclude that in 76% of cases where there was sufficient documentation from which to draw conclusions, the babies might have had different outcomes if alternative care was given.

Heart monitoring

"Problems with accurate assessment of foetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting foetal heartrate patterns, have been cited as factors in many of the cases we have investigated," comments one of the investigators, Professor Zarko Alfirevic, a consultant obstetrician at Liverpool Women's Hospital.

The report found that parents were only invited to take part in reviews in 34% of cases where something went wrong. This was despite a number of incidents where mums and dads said they wanted to find out more. Among them was Kym Field from Cambridgeshire whose son, Alfie, was born with no brain activity as a result of missed care opportunities.

Kym says: "We had to say goodbye before we even had chance to say hello. It was, to this day, the hardest thing we have ever had to do. Instead of organising a date for family to come and meet our perfect new bundle, we arranged his funeral."

Recommendations

The report makes a number of recommendations for how doctors and midwives could improve care. These include:

• Ensuring that all women admitted during labour are formally assessed to decide on the appropriate level of foetal monitoring
• Informing health professionals of any risks to the newborn baby's health in a timely and consistent manner
• Giving key members of staff clinical oversight, particularly in complex or unusual cases

'Unacceptable'

Commenting on the report in a statement, Clea Harmer, CEO of Sands, the stillbirth and neonatal death charity, says: "I am deeply shocked by this unacceptable rate of harm to babies in labour. The failure to carry out thorough reviews of what happened is inexcusable and must change.

"Judging by the quality of reviews done many parents are not getting clear answers about events leading up to the death or harm of their baby. It’s essential that parents’ perspectives of their care are part of the lesson learning process: parents remember, often with searing clarity, the events surrounding their baby’s delivery and their version of events and questions must be taken seriously.