Could baby death and brain injuries have been prevented?

21st June 2017 Clinical Negligence

Today the 'Each Baby Counts' Inquiry by the Royal College of Obstetricians and Gynaecologists (RCOG) was published following their review of more than 700 recent neonatal deaths and injuries. In a shocking statistic the study revealed that three in every four of the children could have had a different outcome had they received different care.

The report as reported in the BBC looked at all 1,136 stillbirths, neonatal deaths and brain injuries that occurred on UK maternity units during 2015 of whom 126 were stillborn, 156 died in the first week of birth and 854 suffered a severe brain injury that was noted within the first week of birth.

It is disappointing that in more than a quarter of cases, the investigation undertaken by the hospital was not sufficient to determine whether the outcome could have been different. It is not known whether the deaths of these children could have been avoided because the local investigation was not sufficient which is extremely concerning for the families involved. Parents were only involved in a third of the local reviews and the fact devastated parents were not kept informed regarding the investigation will lead to questions regarding the Duty of Candour and whether parents are being told the full story.

The main issues were problems with accurate assessment of foetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting baby heart-rate patterns by way of a CTG trace.

Recommendations were made in the report such as all low-risk women are assessed on admission in labour to see what foetal monitoring is needed; members of staff have annual training on interpreting baby heart-rate trace and a senior member of staff must maintain oversight of the activity on the delivery suite. Whether such measures can be implemented given the current costs-cutting measures is unclear but the current situation is concerning following RCOG's inquiry.

One factor that hospitals can improve is the information provided to parents. A further recommendation was made in that all trusts and health boards should inform the parents of any local review taking place and invite them to contribute. Parents should always be kept fully informed about the investigation and hospital trusts have a duty to be open and honest when mistakes are made.

To read the full report summary please click here.

For a confidential discussion with Nick and the team about any concerns you may have about yourself or a loved one please do not hesitate to get in contact via the form or by calling 0800 054 6412.


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Nicholas Young is a Senior Associate Solicitor located in Manchesterin our Clinical Negligence department

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