Birth trauma reports not good enough says RCOG report

A SIGNIFICANT number of local investigations into cases of stillbirth, early neonatal death and severe brain injury occurring as a result of incidents during term labour are of "poor quality", according the first annual report of a new initiative by the Royal College of Obstetricians and Gynaecologists.

Each Baby Counts is a national quality improvement programme launched by the RCOG in October 2014 which aims by 2020 to halve the number of such incidents by drawing together lessons learned from a review of all local investigations across the UK.

Interim data from the 2015 annual report reveal that 921 babies were reported to the Each Baby Counts programme, with 654 (71 per cent) classified as having severe brain injuries and 147 (16 per cent) suffering early neonatal death and 119 (13 per cent) stillborn.

Of 610 completed reports, 599 had a local investigation of some kind with 204 assessed by Each Baby Counts reviewers to date. The reviewers found that 27 per cent of reports were of "poor quality" as they did not contain sufficient information for the care to be classified. Of those that passed the initial quality checks, 39 per cent contained no actions to improve care or only made recommendations which were solely focussed on individual actions.

Although 96 per cent of reviews were made up of multidisciplinary teams, including midwives and obstetricians, only 62 per cent included a neonatologist, 44 per cent a member of the senior management team and 10 per cent an anaesthetist. Only 7 per cent of local review panels included an external expert.

Parents were made aware that an investigation was taking place in only 47 per cent of local reviews and subsequently informed of the outcomes. In only 28 per cent of reviews were parents invited to contribute to the investigation.

Professor Alan Cameron, RCOG vice president for clinical quality and co-principal investigator for Each Baby Counts, said: "This report shows that although some trusts are conducting reviews very well, it is clear that we need more robust and comprehensive reviews, which are led by multidisciplinary teams and include parental and external expert input. Additionally, we need to move to a more standardised national approach for carrying out these investigations to improve future care. The focus of a local investigation should also be on finding system-wide mechanisms for improving the quality of care, rather than individual actions.

“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. The emotional cost of these events is immeasurable and each case of disability costs the NHS around £7million in compensation to pay for the complex, lifelong support these children need – this equates to nearly half of the NHS’ litigation budget.

"Currently, there is a lack of consistency in the way local investigations are conducted. 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 poor quality 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.”

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