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Calls for national approach as report criticises investigations into stillbirths

Investigations into stillbirths, neonatal deaths and severe brain injuries to newborn babies urgently need to improve, the first annual Each Baby Counts report by the Royal College of Obstetricians and Gynaecologists (RCOG) has found.

The report found that, in 25% of cases, parents were not even informed that a review of their baby’s care was taking place, and in 47% of cases they were not invited to contribute to the review.

The report also criticised the make-up of review teams. Only 62% included a neonatologist and 10% had an anaesthetist, while 44% included a member of the senior management team and external experts were only involved in 7% of cases.

Nicky Lyon, parent representative on the Each Baby Counts Advisory Group and co-founder of the Campaign for Safer Births, whose son Harry died of a chest infection at 18 months after suffering brain damage during labour, said: “In the days following Harry’s birth we asked what had gone wrong, but we were ignored. It was only after submitting a formal complaint that we learnt that an investigation was already underway.

“It’s hard to describe how upset, confused and angry we were – the poor communication and secrecy made a terrible situation so much worse.”

Professor Alan Cameron, RCOG vice-president for clinical quality and co-principal investigator for Each Baby Counts, added that there is a lack of “consistency in the way local investigations are conducted”.

“When the outcome for parents is the devastating loss of a baby, or a baby born with a severe brain injury, there can be little justification for poor quality reviews,” he said.

“Only by ensuring that local investigations are conducted thoroughly with parental and external input, can we identify where systems need to be improved. Once every baby affected has their care reviewed robustly we can begin to understand the causes of these tragedies.”

Only 150 of the 599 reviews were judged by the RCOG investigators to be of sufficient quality. Of these, 32 (21%) contained no actions or recommendations for improvement at all and 27 (18%) had recommendations which were wholly focused on individual members of staff, not systematic change.

NHS England has committed itself to halving the stillbirth rate by 2030.

Professor Cameron said a standard national approach for investigations should be introduced.

He recommended that this involve ensuring that the review is led by a multidisciplinary team, with parental and external expert involvement and a focus on recommendations for systematic improvement.

Ben Gummer MP, health minister, called the findings “unacceptable” and said the government was investing in a new system to support reviews of such cases.

Louise Silverton, director of midwifery at the Royal College of Midwives, said the RCM supported a standardised national approach.

“Each one of these statistics is a tragic event, and means terrible loss and suffering for the parents,” she said. “We must do all we can to reduce the chances of these occurring. This report shows that this is not the case and improvements are needed as a matter of urgency.”

University of Leicester researchers recommended last month that the NHS should offer post-mortems on all stillbirths and neonatal deaths.

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