This Baby Loss Awareness Week JMW calls for change

13th October 2021 Clinical Negligence

What is Baby Loss Awareness Week and why is it so important?

Baby Loss Awareness Week is the initiative of the Baby Loss Alliance; a working group of charities including SANDS, Tommy’s, Kicks Count, and Baby Lifeline to name but a few.

Baby Loss Awareness Week is a time for those affected by the loss of a baby to come together and commemorate their babies’ lives. It also provides a more visible opportunity to raise awareness of the various causes of baby loss, and push for improvements to maternity care and bereavement services.

The week culminates in a day of remembrance (15 October) where people are encouraged to light a candle and form a ‘wave of light’.

What does Baby Loss Awareness Week mean for my clients?

Babies born after loss are known as “rainbow babies”. As a rainbow baby myself, I know just how important Baby Loss Awareness Week is and understand the need to promote awareness of what some still see as a taboo subject. In addition, as a solicitor who regularly acts for women who have suffered the avoidable loss of a baby, my focus is very much on pushing for improvements in maternity care.

Losing a baby at any stage is devastating, and whilst it is more common than people think, it remains a taboo subject. Women often blame themselves for the loss of their child, or worry about being blamed, even though there was nothing that that could have done to change the outcome. To compound matters, many women who lose a baby will then go on to develop mental health issues, which themselves carry a stigma.

Baby Loss Awareness Week enables those affected to come together and share their experience with people who understand baby loss the most. It provides a safe space to grieve and talking about loss can, in itself, prove cathartic.

As noted above, it also provides a dedicated opportunity to raise awareness of the various causes of baby loss, and push for improvements to maternity care and bereavement services.

One of my clients who is determined to raise awareness and push for improvements is Aimée. Aimée’s son, Alfie, was stillborn in July as a result of multiple failures which occurred during her pregnancy and labour. You can read details of Aimée’s story here.

Why are so many babies dying needlessly in the UK?

The vast majority of my cases which concern the loss of a baby involve stillbirth. A baby is ‘stillborn’ if it has died in the womb either before or during labour.

Some stillbirths are unavoidable and occur as a result of unexpected complications such as congenital defects or as a result of the mother having an underlying and undiagnosed medical condition. There are also some babies who die as a result of as yet unknown reasons. Charities like Tommy’s are leading the way in researching these possible causes.

Giving birth can be a stressful time for both mothers and doctors but, surprisingly, the stillbirth cases that I have dealt with to date have involved inconceivably simple mistakes.

Such mistakes include:

-       Failures to spot and act upon symptoms of pre-eclampsia (which include severe headache, altered vision, high blood pressure, and pain below the ribs);

-       Failures to carry out basic blood or urine tests designed to check for certain conditions (such as a special urine test to assess the risk of pre-eclampsia);

-       Failures to place ‘high risk’ women (e.g. those with a high or low BMI, gestational diabetes, or Type 2 diabetes) on the correct care pathway / refer them             for obstetric led care;

-       Failures to properly consult ‘high risk’ women and advise them to give birth at a slightly earlier point in time in order to reduce the risk of complications             during the birth itself;

-       Failures to arrange for women to give birth in hospital in the presence of obstetricians instead of at a midwifery led birth centre;

-       Failures to answer telephone calls for help;

-       Failures to properly log telephone calls using dedicated computer systems designed to enable information to be shared between obstetricians and                     midwives;

-       Failures to recognise that a woman’s labour is not progressing as expected which can lead a baby to become distressed.

 What needs to change and how can it be achieved?

Change needs to be affected at all levels of maternity care.

Maternity safety training fund and staffing

The government needs to start by reinstating the maternity safety training fund as a matter of urgency. The fund was introduced in 2016 and led to around 30,000 healthcare professionals receiving enhanced training. However, it was promptly cut and as a result different NHS trusts currently allocate different amounts to improving maternity safety. Baby lifeline’s ‘Mind the Gap’ project found that some trusts invest over £370,000 per year into maternity safety whilst others invested as little as £1,051. It is estimated that re-instating the fund will prevent around 2,400 stillbirths and 1,680 neonatal deaths per year.

The government also needs to consider the ways in which it can improve staffing levels. A recent report published by the Health and Social Care Committee found that 80 per cent of maternity units do not have enough staff to provide, at the very minimum, safe care. Overworked staff further increase the potential for mistakes to be made.

Trust guidelines and procedures

Individual NHS trusts also need to review internal guidelines and procedures, identify any ‘loopholes’, and make sure that their midwives and obstetricians are actually adhering to them. We recognise that from time-to-time mistakes will occur as a result of human error, but this will never justify the loss of a life, and so it is also important that trusts also review their safety net procedures.

Taking Aimée’s case as an example, in a 21st century healthcare system our computers should be able to flag if a woman has certain characteristics which mean that she is ‘high risk’ and so prompt the clinician using the system to ask whether they are on the correct care pathway. However, equally it is all well and good having a computer system to perform certain tasks (such as record telephone important conversation) if the clinician decides not to use it in the first place.

Ask questions

Lots of my clients who have lost a baby report having had a ‘gut feeling’ that something wasn’t right with their pregnancy, but they chose not to ask questions because they didn’t want to be seen as ‘untrusting’ or ‘undermining’. Whilst in a perfect world a woman shouldn’t ever feel the need to question their maternity care, it is equally as important that they do not feel deterred from doing so.



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Lucy Mellor is a Solicitor located in Manchesterin our Clinical Negligence department

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