Inadequate investigations are regularly being carried out into the circumstances surrounding the births of stillborn babies, children who die at less than a week old and those who suffer brain injuries during labour, according to government-funded research.
The Royal College of Obstetricians and Gynaecologists (RCOG)found that reviews into such cases often excluded parents – in a quarter of cases they did not even know an investigation was taking place – and impartial experts.
The Each Baby Counts study revealed that 27% of investigations – known as local reviews – were 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 systematic failings.
The college, whose study was part-funded by the Department of Health, has set a target of halving the number of stillbirths, neonatal deaths and severe brain injuries during term labour (37 weeks or beyond) by 2020. But it warned that failings in investigations could impede progress.
Prof Alan Cameron, RCOG vice president for clinical quality and co-principal investigator for Each Baby Counts, 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 in a quarter of cases.
“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.”
There were 654 severe brain injuries, 147 neonatal deaths and 119 stillbirths during term labour reported to Each Baby Counts in 2015. Of 610 reports completed, 599 have had a local investigation of some kind. More than half of those were found to be inadequate.
Meanwhile, just less tgab half (47%) of parents were made aware that an investigation was taking place and were informed of its outcomes, but parents were invited to contribute in only 28% of cases.
Nicky Lyon, parent representative on the Each Baby Counts advisory group and co-founder of the Campaign for Safer Births, had first-hand experience of being excluded from the investigation process when her son Harry, who died aged 18 months, suffered brain damage during labour.
“In the days following Harry’s birth we asked what had gone wrong, but we were ignored,” she said. “It was only after submitting a formal complaint that we learned that an investigation was already under way. It’s hard to describe how upset, confused and angry we were – the poor communication and secrecy made a terrible situation so much worse.
“Patients and their families should always be at the heart of a review … being included in the process would have made such a difference to our family.”
Each Baby Counts said that parents should always be told that a review is taking place and be invited to participate. It also said external experts should be employed – they were used by only 7% of local review panels – and there should be standardisation of reporting.
Health minister Ben Gummer said: “These findings are 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.”
