An inquiry into the cause of hundreds of deaths of newborn children in the UK has highlighted ‘consistent issues’ with maternity staff accurately monitoring and assessing the health of babies during pregnancy.
The Each Baby Counts inquiry, led by the Royal College of Obstetricians and Gynaecologists (RCOG), looked at 1,136 cases of stillbirths, neonatal deaths and brain injuries that occurred on maternity units during 2015.
In total, 126 babies were stillborn, 156 died within the first seven days after birth and 854 babies had a severe brain injury.
The report concluded that in 727 cases from which it was able to thoroughly investigate the care provided, three out of four babies may have had different outcome had they received different care.
This is a shocking statistic, suggesting hundreds of new lives were either lost, or changed forever, due to failings of those providing care to expectant mothers during labour and birth.
Many hospitals failed to carry out thorough investigations into maternity care
Interestingly, this report has also highlighted another area of major concern.
It has been revealed that around a quarter of the cases were unable to be fully assessed as part of the Each Baby Counts inquiry, as local investigations had not been detailed enough at the time.
This is simply unforgiveable, and we agree with Prof Lesley Regan, president of the RCOG, who has called the situation ‘unacceptable’ and called for change as ‘a matter of urgency.’
In our work at Hudgell Solicitors in supporting people in birth negligence claims, we too often hear how Hospital Trusts have failed to give full answers to parents and families, answers that are only often forthcoming when legal proceedings are started.
How on earth can the death or serious injury to a newborn child not demand a complete, honest and thorough investigation over the care provided?
Under the Duty of Candour, all health trusts have a professional duty to openly and honestly inform patients when things go wrong and to apologise when appropriate.
This simply cannot be happening if Trusts are not carrying out thorough assessments, and must be tackled by Health Secretary Jeremy Hunt.
He launched a new Maternity Safety Action Plan last October, in which the Government committed to providing resources for Trusts to improve their approach to maternity safety, including an £8m fund for maternity safety training.
Pledges have also been made to reduce the number of stillbirths, neonatal deaths, maternal deaths and brain injuries during or soon after labour by 50 per cent by 2030, with a drop of one fifth by 2020.
This report, however, has highlighted the need to keep this area of healthcare under major scrutiny moving forward, to ensure the quality of training and equipment is improved, and rates of baby deaths and injuries fall quickly as promised.
Recommendations have been made that all low-risk women be assessed on admission in labour to see what foetal monitoring is needed, for staff to have annual training on interpreting baby heart-rate traces (CTGs), and that a senior member of staff must maintain oversight of the activity on delivery suites.
Whilst these recommendations are certainly welcomed, it poses a question as to why these basic measures are not already in place on every hospital maternity ward across the country already, and how many lives could have been saved if they were?