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Tag Archive: birth negligence

National Bereavement Care Pathway to Improve Care for Bereaved Parents

Sad couple mourning | National Bereavement Pathway for Bereaved Parents


A group of charities and professional bodies has developed an initiative aimed at improving the quality of care bereaved parents receive when their baby dies, whether during pregnancy or in infancy.

The National Bereavement Care Pathway (NBCP) has been developed by a “Core Group” of national charities and organisations, including stillbirth and neonatal death charity, Sands, premature baby support charity, Bliss, and the Royal College of Midwives. The scheme will be piloted in 11 sites across England, with the hope that it will lead to improved care for parents suffering the loss of their baby.

Launching in October, the NBCP will trial new training, materials and guidelines for medical professionals, helping to improve the care and support parents receive in the aftermath of stillbirth or neonatal death. The new bereavement pathway will be used in cases where parents have lost a child during pregnancy, or up to 12 months after the birth, and is intended to provide equal, effective, high-quality, sensitive and safe care to all parents when their baby dies.

Across the 11 sites chosen as part of the initial NBCP rollout, medical professionals will work closely with the project team to implement the new bereavement pathway, improving the services offered to parents. The sites were chosen as they are broadly representative of capacity, specialism and geography, and will begin implementing the NBCP from October this year.

The sites include:

  • Wirral University Teaching Hospital
  • Liverpool Women’s Hospital Trust
  • York Teaching Hospital NHS Trust
  • Hull & East Yorkshire NHS Trust
  • Heart of England NHS Foundation Trust
  • Walsall Healthcare NHS Trust
  • Northern Devon Healthcare NHS Trust (Barnstaple Hospital)
  • Medway (Maritime) NHS Foundation Trust
  • West Middlesex, Chelsea & Westminster Hospital
  • Barking, Havering & Redbridge University Trust — Queen’s Hospital
  • Ipswich Hospital NHS Trust

Following the successful roll-out of the NBCP at the trusts listed above, the pathway will be introduced at a second wave of pilot sites in April 2018, before the scheme is launched on a national level in October 2018.

Care improvements welcome — but more is needed to prevent stillbirths

The quality of care bereaved parents receive can make all the difference in their recovery following the loss of a baby. While good care can never take away the pain and grief of stillbirth or neonatal death, it can help to improve the long-term outlook, giving parents the help and support they need to begin to rebuild their lives.

News of the NBCP’s launch comes just weeks after a damning report emerged highlighting the UK’s shocking record of stillbirths and neonatal deaths, in which over two dozen NHS trusts were found to have higher than expected rates of perinatal mortality. Every day in the UK, 15 babies die before, during or shortly after birth, leaving thousands of parents facing the trauma of losing their child.

While the UK’s stillbirth and neonatal death rate is falling, it’s still higher than many other countries in Europe. There are also huge regional discrepancies in the number of stillbirths, suggesting that individual hospital trusts must do more to try and prevent infant mortalities.

We welcome the roll-out of the National Bereavement Care Pathway, and hope that it proves successful in delivering improved care for vulnerable parents left heartbroken by the loss of their baby. Stories like that of Louisa Holmes, who tragically lost her unborn baby and was let down by “inadequate” NHS procedures, show that receiving the appropriate aftercare is hugely important in helping parents recover from the trauma of losing a baby.

However, while improving aftercare for bereaved parents is a positive step, more is needed to tackle the issue of stillbirths and neonatal death in the UK, before it can affect expectant parents. Britain has a perinatal death rate higher than many other European countries with a similar population and GDP, so it’s vital that improvements are implemented sooner rather than later.

Hudgell Solicitors is experienced in holding healthcare professionals to account for substandard neonatal care. To find out how we may be able to help you, visit our birth negligence page or contact us today.

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11/08/2017 No Comments

NHS Trusts Must Do More to Prevent Stillbirths and Neonatal Death

Adult holds baby's feet | NHS Hospitals with high rate of stillbirth


Stillbirths and neonatal deaths have a lasting impact, and nothing can prepare parents for the pain of losing their baby. Tragically, 15 babies die before, during or shortly after birth in the UK every day — raising questions about what can be done to prevent and reduce perinatal mortality.

Just last week, a report emerged suggesting that almost two dozen NHS trusts in Britain have higher than expected rates of stillbirths and neonatal death. Some twenty-one hospital trusts are currently labelled “red”, meaning they have an infant mortality rate 10% higher than the European average for that type of organisation.

In 2015, experts began examining the UK’s perinatal death rate. They introduced a traffic light system to highlight trusts where action is needed to improve birth outcomes. Over 12 per cent of the 165 NHS trusts assessed in the study were labelled “red”, while around a third (32.7%) were given an “amber” rating. Troublingly, just 7% were ranked “green”, meaning their perinatal mortality rate is 10% lower than average.

The authors of the study, MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK), have called on individual NHS trusts to investigate the possible causes of the higher rates, and review the quality of care they provide. Working with the Healthcare Quality Improvement Partnership, plans are in place to develop a standardised perinatal mortality review tool that will allow hospitals to monitor and review stillbirths and neonatal deaths— with a goal to reduce instances of infant mortality in the future.

The 21 NHS trusts with high rates of stillbirths and neonatal deaths

NHS hospital with high rate of stillbirths and neonatal deaths

Below, we list the 21 NHS trusts deemed “red” by the MBRRACE-UK report.

  • Belfast Health & Social Care Trust
  • Birmingham Women’s NHS Foundation Trust
  • Cambridge University Hospitals NHS Foundation Trust
  • Guy’s and St Thomas’ NHS Foundation Trust
  • Liverpool Women’s NHS Foundation Trust
  • Sheffield Teaching Hospitals NHS Foundation Trust
  • University Hospitals Bristol Foundation Trust
  • East Lancashire Hospitals NHS Trust
  • Homerton University Hospital NHS Foundation Trust
  • The Royal Wolverhampton NHS Trust
  • Royal Berkshire NHS Foundation Trust
  • Sandwell & West Birmingham Hospitals NHS Trust
  • Southern Health & Social Care Trust
  • The Dudley Group NHS Foundation Trust
  • The Shrewsbury and Telford Hospital NHS Trust
  • Worcestershire Acute Hospitals NHS Trust
  • Countess of Chester Hospital NHS Foundation Trust
  • Kettering General Hospital NHS Foundation Trust
  • Royal United Hospitals Bath NHS Foundation Trust
  • Salisbury NHS Foundation Trust
  • Dorset County Hospital NHS Foundation Trust

Despite these worrying statistics, the report does show that the UK’s stillbirth rate fell by 8% between 2013 and 2015 (when the study was carried out), and that the number of cases is generally falling year-on-year. The Government’s long-term ambition is to halve the total number of stillbirths and neonatal deaths by 2030, and these statistics do suggest that things are moving in the right direction.

However, while the UK’s stillbirth and neonatal death rate is falling, it remains higher than other European countries. In 2015, the rate was 3.87 per 1,000 total births — higher than European countries with a similar population and GDP. There is also considerable variation between NHS trusts across the country, highlighting the need for individual hospitals to review the care and treatment they provide, and do more to prevent infant mortalities.

Could Hospital Negligence be Responsible for Hundreds of Baby Deaths and Brain Injuries?

Pregnant woman in grey jumper | Stillbirths and neonatal deaths

In a similar study released last week, the RPOG (Royal College of Obstetricians and Gynaecologists) concluded that more than 550 babies who died or suffered brain injury shortly after birth may have had different outcomes had hospital care been better and more comprehensive.

In the wake of the report, the RPOG are calling for a raft of actions to be taken to improve care in hospitals with a high infant mortality rate. The organisation has launched an ‘Each Baby Counts’ campaign, calling on the government to take a tougher line on NHS trusts which currently fall below the expected standard in neonatal care.

Raising Awareness of Neonatal Death for Sands Awareness Month

June is Sands Awareness Month, an annual campaign raising awareness of stillbirths and neonatal death. As part of the 2017 campaign, Sands is highlighting the tragic fact that 15 babies die every day in Britain, and has launched a #15babiesaday initiative to get people involved in the event.

Sands was founded in 1978 by a small group of parents left devastated by losing their babies. Ever since, the charity has campaigned tirelessly to raise awareness of the impact of stillbirths and neonatal death. The charity provides help and support to families who have suffered the death of an infant, and also works with the government to advise on how hospitals and healthcare trusts can do more to prevent and reduce neonatal mortality.

For more information on Sands and ideas on how you can get involved in the #15babiesaday campaign, click here.

Hudgell Solicitors is experienced in holding healthcare providers to account for substandard antenatal and neonatal care. To find out more, visit our dedicated birth negligence page or call our team today.

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27/06/2017 No Comments

Hospital Trusts failure to fully investigate causes of hundreds of baby deaths and injuries is unforgiveable

new born baby


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?

Related News:

BBC 

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21/06/2017 No Comments

New guidelines for care of children with complex health problems must lead to improved standards across country

new born baby holding hand


A Care Quality Commission (CQC) review has highlighted how major improvements are needed to deliver consistently high levels of care nationally, in both hospitals and within the community, for newborn babies and infants with complex health problems.

The review focused on problems before birth, such as the detection of health problems during pregnancy through screening and anomaly scans, the diagnosis and management of newborn babies with deteriorating medical conditions, and the management of infants requiring respiratory support in the community.

It drew on a sad case from 2001, in which baby Elizabeth Dixon was born prematurely, suffering brain damage as a result of missed high blood pressure. She died shortly before her first birthday in after a failure to correctly maintain her tracheostomy tube.

Many concerns were raised over aspects of Elizabeth’s care, and this review was undertaken to consider whether these areas of care have improved nationally since, or whether further improvements still need to be made.

CQC findings make concerning reading over continued risks to hundreds of babies’ health

Sadly, the findings have made concerning reading, in that a significant risk to hundreds of babies and children has been highlighted due to inconsistent practices and a lack of clear guidance on treatment nationally.

In its summary, the CQC said it had ‘found variation nationally, potentially due to the lack of national guidance about the management of at-risk babies and infants, and inconsistent processes to communicate information from one specialty team to another.’

Professor Ted Baker said the lack of clear guidance spread to packages of support for families with children who were ventilated at home, highlighting ‘serious inconsistencies’, not only in the way they were designed, but also with regards to discharge arrangements and the level of training and skills of some of the staff looking after those children.

As experts in handling cases of birth negligence, we at Hudgell Solicitors fully understand the difficulties many families face when a child has complex medical needs. We know how daunting it can often be for parents when liaising with the various medical professionals to reach the correct diagnosis and access the most appropriate services.

For many parents, it must have felt they were being badly let down by the medical profession when they have needed support, and clarity, the most.

New guidance protects patients and medical professionals from life-threatening errors

Too often in our work as medical negligence claims specialists, we see life-threatening errors made because there simply has not been clear enough guidance follow for medical staff to follow with confidence.

Break-down in communication is also a common problem, leading to completely avoidable errors being made. Quite simply, nothing in healthcare should be left to chance, and strict policies and procedures should be in place to ensure all patients – no matter what age or in what circumstance – receive the best quality care.

Such strict policies and clear guidelines not only protect patients, but also importantly the medical staff themselves, who in all circumstances want to provide the best care, but are often let down by poor direction.

In our experience, it is certainly the case that inconsistencies in the standard of care being provided nationally, or breakdowns in communication, can result in a poor outcome.

It is with that in mind that we are pleased to see these issues relating to this very vulnerable group of patients being highlighted in this review.

It is also pleasing to see it has resulted in firm plans for new clear guidelines to be developed, which should lead to improvements in the standard of care, and less avoidable serious illnesses and deaths across the UK.

The recommendations have been supported by the National Institute for Health and Care Excellence (NICE), the Royal College of Nursing (RCN), the Royal College of Paediatrics and Child Health (RCPCH), the Royal College of Midwives (RCM) and the British Association of Perinatal Medicine (BAPM).

Let’s hope today marks the start of better care and support for young people who need medical care to be the best it can be to help them make the best possible start to life.

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07/07/2016 No Comments

More than a quarter of mothers-to-be say midwives and doctors were ‘dismissive’ of their concerns during pregnancy

Doctors Hospital Corridor Nurse Pushing Gurney Stretcher Bed


More than a quarter of people questioned in a survey on the quality of maternity care said they felt midwives and doctors had a ‘dismissive’ or ‘not overly concerned’ attitude during their pregnancy and labour.

And more than 4 in 10 admitted to feeling reluctant to call them with their concerns – potentially putting the lives of themselves and their unborn babies at risk should any serious complications arise.

With the quality of birth care currently under the spotlight due to high rates of stillbirths in the UK, new national guidance was recently issued by NHS England chief executive Simon Stevens in which midwives were told by NHS England to ‘better listen to warnings from expectant mothers’.

It came after a damning report last year, from an enquiry led by the University of Leicester, claimed more than 60 per cent of stillbirths in the UK might be avoided if midwives avoided basic errors and acted better on warnings from concerned parents.

Half were found to have occurred after women contacted maternity units themselves because they were fearful that their baby’s movements had slowed, changed or stopped, highlighting the need to listen to patients’ concerns.

Now, new research from medical negligence specialists Hudgell Solicitors, who support many parents following traumatic and negligent care during birth, has revealed a worrying lack of perceived empathy and support from maternity teams towards patients across the country.

More than four in 10 Brits who took part in the survey said they felt reluctant, or didn’t call midwives and nurses during pregnancy with their concerns.

More than a quarter (26%) surveyed also said they felt the attitude of a doctor or midwife was dismissive or not overly concerned during the pregnancy. A quarter (25%) said they felt the same during labour itself.

Almost a fifth of British women (17%) revealed they had felt uncomfortable with the treatment they received while giving birth, and more than one in 10 Brits said they had experienced birth related injuries (15%) themselves, with almost a third (31%) admitting to being concerned about suffering injuries during birth while pregnant.

Helena Wood, a specialist in handling birth negligence claims at Hudgell Solicitors, says the results highlight a clear need for a change of approach by many maternity care providers across the country.

“This research suggests that, despite a mum-to-be often knowing when something is wrong through instinct and knowing their bodies, there is still some way to go in terms of making them feel that their concerns are being listened to, and acting on those concerns where necessary.

“We appreciate that midwives and doctors are the experts and that there are thousands up and down the country providing the very best care and support, often saving lives of mothers and babies when things don’t go smoothly. We also know that for many mums, pregnancy can be a worrying time, and often they will worry when things are fine.

“However, the other side to this is that there are still too many mothers feeling unable to raise their concerns, or that their concerns are not taken seriously, despite recent research and statistics pointing to a need for their concerns to be heard and considered.

“Unfortunately, a repeating issue we see with our clients, who sadly come to us when something has gone wrong during the birth of their child, is a feeling that concerns raised at stages of their pregnancy were too easily dismissed by midwives and doctors.

“We see the huge pain and devastation caused when a baby is stillborn, a pain which is only intensified when a family learns their baby could, and should, have been born healthy.

“Such errors and great loss often cause long-term emotional and psychological suffering for parents, as the loss of a baby is a life-changing event.

“We welcome the fact the Government has targeted halving the number of stillbirths by 2030, but for this to happen, it is clear that changes are required to ensure mothers’ concerns are taken seriously and appropriate action taken when necessary.”

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25/04/2016 1 Comment

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