This week the Royal College of Obstetricians and Gynaecologists released their second annual progress report, Each Baby Counts, summarising key findings and trends of all stillbirths, early neonatal death (death within 7 of birth) and severe brain injury occurring during labour at term for data from 2016. The report highlights progress that has been made to prevent these tragic events and focuses on areas of improvement with the overall aim of halving the rates by 2025.
As a clinical negligence lawyer, acting for families who have suffered these tragic events, the report makes for very worrying reading. Still, the same failings identified from the report are ones that we see time, and time again, in our cases.
The most worrying and tragic statistic to emerge from the report is that in 71% of all of the cases, different obstetric management might have altered the outcome for these babies and prevented their deaths or significant injuries. Although, every case is different on the facts, the main themes were (and not mutually exclusive):
- Risk recognition including failure to escalate/act upon risk/transfer appropriately and incorrect assessment of risk (72%)
- CTG and blood sampling including fetal blood sampling, failure to act upon suspicious or pathological CTG, errors of interpretation of CTG, CTG technique/equipment (60%)
- Education and training issues including failure to properly supervise individuals, failure to follow local guidelines of best practice, lack of skill, experience or competence (59%)
- Individual human factors including lack of team leadership, lack of situational awareness, fatigue and stress (50%)
- Team communication issues including poor record keeping/written documentation and poor intra- or inter-professional communication (49%)
- Delayed management of delivery including delay in delivery due to waiting for results and availability of staff/theatre (41%);
- Management of labour including induction/augmentation issues (31%);
- Management of delivery including anaesthetic issues and inappropriate delivery technique (25%);
- Intermittent auscultation including failure to act upon suspicious findings, errors of interpretation/failure to detect pathology, technique/equipment/timing (21%)
- Patient factors including communication issues and access issues (16%)
Neonatal management was also considered, and it was identified that in 46% of cases, different neonatal care might have altered the outcome. The highest percentage of cases related to lack of situational awareness; resuscitation; the most appropriate person(s) not present at delivery; and neonatal team not made aware of risk factors in a timely manner.
The Every Baby Counts report has been released in the same month as Baby Lifeline’s report, Mind the Gap. That report highlighted similar concerns about maternity care and the importance of training and appropriate staffing levels. An additional important statistic from Baby Lifeline’s report is that fewer than 8% of trusts provided all training elements of the Saving Babies’ Lives Care Bundle – a nationally recommended tool to reduce stillbirth (see my earlier blog post).
Another very concerning statistic from the Each Baby Counts report, which is so important to parents, is that in only 41% of cases, families were invited to be involved in the investigation undertaken by the Trust about what happened in their baby’s care and treatment.
Getting answers about what happened is always at the forefront of my clients’ minds. Engaging parents in the investigation is imperative; it helps them understand what went wrong, and goes a little way in helping them come to terms about what has happened.
Our clients tell us that by not being involved in the investigation process, they often feel that there is an “us and them” attitude from the Trust. They feel that issues and facts are being “covered up” behind closed doors. This means that even if they receive a copy of the investigation report (and often they do not, and are not aware that an investigation has been undertaken) they feel that the Trust is not being honest in their reasons for what happened to their baby, despite the duty of candour.
Another facet to this issue, which the report recommends, is that all local reviews should have the involvement of an external panel member to give an independent view. This, again, is so important to families and builds a relationship of trust; that the clinicians are being open and honest with them about what has happened and they are not “closing rank”.
Parents need to be made aware of the investigation, involved in the process and supplied with a copy of the report. If they are not, then it is my advice to parents to request disclosure of the Each Baby Counts report and any other investigation report prepared by the Trust, which you are entitled to see, as well as all related documents, correspondence and witness statements taken from clinicians in preparation of the report(s). This might go some way to answering the questions that you have. The reports started to be produced in 2014/2015 and therefore should be available to you on request, if you have suffered a stillbirth, your baby died in the 7 days after birth or your child has suffered a significant brain injury during your labour and delivery. As part of our investigation process relating to clinical negligence claims we routinely obtain the investigation report(s) and any documents relating to the Every Baby Counts review.
If you have received a copy of the investigation report and would like some advice on the conclusions reached, or if you have any concerns regarding about your antenatal, obstetric care or care received by your baby and would like to speak to a member of our team, click here to contact us.