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Many baby deaths in NHS are avoidable if best clinical practice followed, report says

Three quarters of babies who died during or shortly after birth or who suffered serious brain injury could have had better outcomes if their NHS care had adhered to best practice.

An analysis of all stillbirths, neonatal deaths and brain injuries that occurred during childbirth in 2015 by the Royal College of Obstetricians and Gynaecologists’ (RCOG) has identified key clinical actions needed to prevent future cases.

Co-principal investigator, Professor Zarko Alfirevic, consultant obstetrician at Liverpool Women’s Hospital, said: “Problems with accurate assessment of fetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting fetal heartrate patterns, have been cited as factors in many of the cases we have investigated.”

Each Baby Counts is a national quality improvement programme, launched in October 2014, aiming to halve the number of babies who die or are left severely disabled as a result of preventable incidents occurring during term labour (after 37 weeks) by 2020.

Alfirevic added: “This is the first time the Each Baby Counts team has been in a position to identify and share the lessons learned across the whole UK maternity service. However, until every incident is thoroughly investigated and important lessons identified locally, our understanding of the national picture will remain incomplete.

“The focus of a local investigation should be on finding system-wide solutions for improving the quality of care, rather than actions focusing only on individuals.”

The investigation team has now conducted 2,500 expert assessments of the local reviews into the care of 1,136 babies born in the UK in 2015 – 126 who were stillborn, 156 who died within the first seven days after birth and 854 babies who met the eligibility criteria for severe brain injury.

The reviewers concluded that 76% might have had a different outcome with different care.

This finding was based on 727 babies where the local investigation provided sufficient information to draw conclusions about the quality of care.

A quarter of the local investigations were not thorough enough to allow full assessment.

The recommendations are aimed at doctors and midwives working in maternity units across the UK and centre around:

Fetal monitoring – formally assessing all low risk women on admission in labour to determine the most appropriate fetal monitoring method; following NICE guidance on when to switch between intermittent and continuous monitoring during labour; ensuring all staff have documented evidence of appropriate annual training

Neonatal care – paediatric/neonatal teams informed of pertinent risk factors in a timely and consistent manner

Human factors – understanding ‘situational awareness’ to ensure the safe management of complex clinical decisions; key members of staff maintaining appropriate clinical oversight; seeking a different perspective to support decision making, particularly when staff feel stressed or tired; ensuring everyone understands their roles and responsibilities when managing a complex or unusual situation

Professor Alfirevic continued: “We urge everyone working in maternity care to ensure the report’s recommendations are followed at all times. Trusts and Health Boards have a role to play in supporting their staff to implement the recommendations, ensuring staff tasked with fetal monitoring interpretation receive annual training, promoting the development of non-clinical skills such as situational awareness and providing multi-disciplinary training to support good team working.”

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