They examined the cases of 1,136 babies born in 2015 – of which 126 were stillborn, 156 died within a week of birth, and 854 suffered severe brain damage. The report concluded that three out of every four babies would have had survived had they received better care.
Despite this information, local investigations into the majority of cases were not thorough enough to enable the report authors to fully assess what went wrong.
In-depth review could only be conducted for 727 cases
Investigation revealed a myriad of problems Professor Zarko Alfirevic, a consultant obstetrician at Liverpool Women's Hospital, and lead author of the report remarked that 'problems with accurate assessment of fetal well-being during labour and consistent issues with staff understanding and processing of complex situations – including interpreting foetal heart rate patterns – have been cited as factors in many of the cases we have investigated.”
Whilst CTG scans are difficult to read and can often be mixed up with the mother’s heart rate – in many cases, midwives are so extremely busy that they do not have time to check the heart rate regularly. They then miss the warning signs that the baby is in distress, which would prompt them to intervene in the delivery.
The UK's stillbirth rates are amongst the highest in Europe. Maternity wards in the UK are becoming increasingly stretched due to a rising birth rate, understaffing and the fact that mothers are getting older – making labour more complex.
“The emotional cost to each family is incalculable and we owe it to them to properly investigate what happened and to ensure the individuals and the healthcare trusts involved take the steps needed to avoid making the same mistakes again,” emphasised Professor Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists.
However, Alfiervic was quick to note that “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.”
Report also called for new measures to reduce the mortality rate
The Each Baby Counts initiative aims to halve the number of babies who die or are left severely disabled as a result of preventable incidents by 2020. They have therefore recommended that midwives conduct more regular checks on baby’s heart rates during labour, and include senior staff such as a senior registrar, consultant or senior midwife so that they may have a ‘helicopter view’ of the delivery.
The report also suggested that all women at a low-risk of a complex labour, should be assessed on whether they need continuous monitoring or not, upon admission. It also called for staff to take proper breaks if they feel stressed or tired and recommended ‘situational awareness’, or seeking second opinions from other staff when they feel stressed or tired.
The investigation comes hot on the heels of one launched only two months ago by Health Secretary Jeremy Hunt on nine needless baby deaths in Shrewsbury and Telford Hospital from September 2014 to May 2016. MIMS
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