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Each Baby Counts: Latest report by Royal College shows continued need for parental involvement in investigations

Each Baby Counts: Latest report by Royal College shows continued need for parental involvement in investigations

Firstly, it should be noted that cases of a tragic nature in maternity are rare, and that women should expect to go into pregnancy and labour with expectations of having a healthy baby and a positive experience; however, these rare cases are also important to learn and adapt from, as they can devastate life for all involved.

The Royal College of Obstetricians & Gynaecologists has released the latest Each Baby Counts report today, which investigates tragic cases where full term babies (37 weeks and above) died during labour and were consequently stillborn, babies that died 7 days after birth, and babies that were severely brain injured.

Of over 670,000 babies born in the UK in 2017, 1,130 full term babies were stillborn (died during labour), died within 7 days of being born, or were severely brain injured. Most of the cases reported were babies with severe brain injuries (850). This is nearly 4 a day. Around 3 out of the 4 babies (72%) were found to have possibly been avoided with different care.

Improving Care

The Royal College made several recommendations to improve care, one of which was the involvement of parents in local investigations.

Involve Parents

As has been highlighted by several reports looking at improving learning from tragic outcomes, involving parents is a crucial element to understanding where things can improve in terms of management of the pregnancy/birth/afterwards, but also communication throughout. The Each Baby Counts report has shown that parental contribution in the investigation has improved from 41% to 50%, but this is still not enough. Big strides need to be taken to reach out to parents during the investigative process.

Only a third (33%) of parents were told about the investigation and/or informed of the outcome.

Other key learning points from the report are the following:

  • Cognitive biases – This relates to not correctly identifying a potentially developing problem during care, having an impact on providing timely care.
  • Loss of situational awareness – The RCOG have stated that it is important to understand when situational awareness is lost and how to minimise this to improve safety.
  • Team dynamics in multi-professional working  Issues with dynamics between different team members can lead to problems in identifying when to escalate a potential problem, and also the RCOG noted a consequential lack of assertiveness in executing what should be done next.
  • Challenging a decision – The RCOG have stated the importance for challenging decisions you disagree with, and has recommended that a third party should be called upon if needed to provide a fresh perspective.
  • Timely reviews by the obstetric team – If the on-site obstetric team is unavailable and there an urgent medical review is needed by a member of the team the consultant needs to be informed.
  • High-quality handover – High-quality handovers are necessary to ensure the momentum in escalating is upheld and maintaining situational awareness as a team.
  • Emergency escalation – It has been found that incorrect methods of emergency escalation delay urgent assistance. The RCOG has recommended that all staff are familiar with the location of local emergency buzzers and switchboard escalation protocols.

Recommendations for Your Maternity Team

  1. Human factors and behaviour – There needs to be research carried out to find out take “human factors” related learning from the report and put it into practice on the frontline of maternity.
  2. Workload and the workforce – The RCOG calls for several pieces of work looking at what safe staffing levels and standards look like in order to guide national policy.
  3. Communication – Measures should be taken to ensure that all staff in the maternity team know what the unit’s emergency communication and escalation procedures are. The RCOG recommends that this is mandatory during induction training and also multi-professional simulation training.

In Conclusion

The UK remains a very safe place to have a baby, and of the thousands of babies born every day this report relates to a tiny proportion (4). This is not to diminish the pervasive harm done to the families and staff involved in these tragic cases. As such, learning must happen in order to make strides in reducing avoidable harm.

Every day in the UK, four babies that go to term (37 weeks or above) die during labour, in the 7 days following, or suffer a severe brain injury. Around 3 out of 4 of these babies could have had had a different outcome with different care. As such, the RCOG has made recommendations relating to improving care, which should now be made a national priority.





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