Study reveals that investigations into baby deaths are often inadequate

Posted: 10/06/2016

The Royal College of Obstetricians and Gynaecologists (RCOG) has published a preliminary report into how problems during labour are investigated, warning that there are too many poor quality investigations when babies die or are severely brain damaged during labour.

More than 900 cases have been referred to the programme. Of the 204 investigations reviewed, 27% were found to be of poor quality and of those that passed initial quality checks, 39% contained no actions to improve care or made recommendations solely focused on individual actions, rather than systemic failings. 

The report says all investigations should be robust, comprehensive and led by multi-disciplinary teams, including external experts and parents. In nearly a quarter of cases, parents did not even know an investigation was taking place. 

The inquiry; Each Baby Counts, has been set up to ensure lessons are learnt when something goes wrong. A target of halving the number of stillbirths, neonatal deaths and severe brain injuries during term labour by 2020 has been set by the college, whose study was part-funded by the Department of Health. But it warned that failings in investigations could impede progress. 

In the UK in 2015, out of 800,000 births, after at least 37 weeks of pregnancy, there were:

• 654 babies classified as having severe brain injuries
• 147 neonatal deaths (within seven days of birth)
• 119 still births. 

In all cases, the babies had been healthy before labour began. 

Of 610 reports completed, 599 have had a local investigation of some kind. More than half of those were found to be inadequate.

Professor Alan Cameron, vice-president of the RCOG and a consultant obstetrician in Glasgow, said: "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 found. The emotional cost of these events is immeasurable, and each case of disability costs the NHS around £7 million in compensation to pay for the complex, lifelong support these children need."

Judith Abela, acting chief executive at Sands, the stillbirth and neonatal death charity, said it wanted a more effective review process involving parents. "Parents' perspective of what happened is critical to understanding how care can be improved, and they must be given the opportunity to be involved, with open, respectful and sensitive support provided throughout," she commented.

Health minister Ben Gummer said the findings were unacceptable. "We expect the NHS to review and learn from every tragic case, which is why we are investing in a new system to support staff to do this and help ensure far fewer families have to go through this heartache," he explained.

Louise Silverton, director for midwifery at the Royal College of Midwives, said she supported proposals for ensuring all investigations were carried out to the same high standard, but this was not always easy. "All healthcare professionals must, of course, be rigorous in their practice," she said. "However, they are often working in systems that do not support best practice, and the safest and highest quality care as well as they should. 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 this occurring. The report shows that improvements are needed as a matter of urgency."

Rebecca Morgan, an associate in the clinical negligence team at Penningtons Manches, comments: “Sadly, we have acted for many parents who have either lost their baby or whose baby has been severely brain damaged during labour. These parents may wish to pursue a clinical negligence claim to obtain answers as to what went wrong and to identify whether the death or injury could have been avoided with different care. Often this is something which could be addressed more cost effectively by the hospital’s own investigation into such events provided this is thorough and involves the parents. As the RCOG report has revealed, this is frequently not the case and is one of the reasons why parents seek to instruct us.

“Parents wish to ensure that any mistakes that are identified in the care they have received do not happen again so other families do not experience their anguish. We hope this report encourages hospitals to take action so that investigations are improved.”

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