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Working together towards safer maternity care – progress and next steps

Working together towards safer maternity care – progress and next steps

James Titcombe – April 2019


In March 2015, the Morecambe Bay Investigation report1 was published. The report looked at the provision of maternity care at Furness General Hospital (FGH) between 2004 and 2013, finding ‘…a lethal mix’ of failings that had contributed to the deaths of 16 babies and 3 mothers.

One of the babies that died was my own son Joshua, who passed away following serious failures in his care in November 2008.

In the years since, improving the safety of maternity services in England has been high on the national agenda and in November 2015, the UK government announced a new ambition to halve the rate of stillbirths and infant deaths in England2.

There are encouraging signs that progress is being made. In 2016 a new Saving Babies’ Lives Care Bundle (SBLCB) was launched3. An independent evaluation4 of the care bundle published last year found a 20 per cent reduction in the stillbirth rate at the 19 maternity units where it was implemented, suggesting 600 lives could be saved if the same results were replicated nationally.

Version 2 of SBLCB5 was launched last month by NHS England and for the first time, implementation of the bundle is set to be mandated for every trust in England by inclusion in the NHS contract.

Learning from harm

In 2017, NHS Resolution published a thematic review looking at data collected from five years of cerebral palsy claims6. The review concluded that ‘the quality of SI investigations has repeatedly been found to be poor with very little or no training for investigators across the NHS.’

In 2018, the Royal College of Obstetricians and Gynaecologists’ Each Baby Counts programme published their second major report7 looking at the care of term babies who were either stillborn, died shortly after birth or were at risk of brain damage in England in 2016.

The review found that 674 babies (71 per cent) might have had a different outcome with different care. The report also highlighted the variability in the quality of the local investigations following these tragic events.

Improving the quality of investigations and learning following adverse events in maternity services has been an area of considerable focus in recent years. From 1st April 2018, the new Healthcare Safety Investigations Branch (HSIB) was given the remit to investigate all term stillbirths, maternal deaths and cases where term babies were indicated as being at risk of hypoxic brain injury.

HSIB has recently announced8 that the roll-out of this programme is now complete, meaning than from 1st April 2019, 100% of such cases will now be investigated independently via this new approach.

This is significant and welcome progress, but there still remains a need for local organisations to ensure they have the skills and capacity to carry out their own investigations into cases that fall outside HSIB’s remit, ensuring that families and staff affected by adverse events are properly supported and that effective investigations take place to drive meaningful learning.

What is Baby Lifeline doing to help?

I’ve been an ambassador for Baby Lifeline for some time and from January this year, it’s been a privilege to work for the charity on a part time basis. Baby Lifeline is unique in that it responds to national reports and recommendations to develop training packages to support front line staff to implement change.

The Baby Lifeline Implementing Saving Babies’ Lives training programme is one example of this. This package of training has been developed, and is delivered, by frontline clinical experts. These experts are actively involved both in caring for babies and their families, and were also the lead contributors in the development of Saving Babies’ Lives Version Two.

Last month I was able to attend another one of Baby Lifeline’s training courses, the CTG Masterclass taught by Mr Edwin Chandraharan. There is a well-documented need for multi-professional improvements in CTG interpretation and monitoring in maternity care for decades, and indeed, providing training in CTG interpretation is a key element of SBLCBv2.

The approach Edwin teaches has been implemented at St George’s Maternity Unit, London, which won a prestigious HSJ award9 in 2016, following reductions in both adverse outcomes and emergency c-section rates at the trust. Over the past few months, I’ve had many conversations with maternity staff across the country who are seeing similar improvements after staff have completed and implemented this training.

Baby Lifeline is currently working to develop a new training package designed to provide staff with practical training in the area of incident investigation, including family engagement, supporting staff, and using systems and human factors-based approaches to identify learning and improvement opportunities. I’m excited to be involved with this work.

What more needs to be done?

It remains a sad fact that around 15 babies are stillborn or pass away within their first four weeks of life in the UK. The latest findings from Each Baby Counts suggest, just as in Joshua’s case, that many of these outcomes could be avoided with different care.

A key aspect of providing safe maternity care, for which there is now widespread consensus10, is the need for all trusts to have in place a high quality multi-disciplinary training programme. However, Baby Lifeline’s own research11 has found significant gaps in the quality and consistency of maternity training.

In 2016, the UK government launched a one-off £8.1m Maternity Safety Training Fund (MSTF), distributed by Health Education England. A recently published independent evaluation of the fund12 found that over 30,000 training places were delivered through the scheme achieving ‘…positive and sustainable learning’. However, the report warns that ‘without ongoing financial support, there is a risk that the benefits of the MSTF initiative will…diminish.’

I’ve seen first-hand the difference Baby Lifeline training can make.  If we are serious about achieving the ‘halve-it’ ambition, it’s clearly vital that funding is made available so that all trusts are able to put in place a high-quality and sustainable multi-disciplinary training programme  to support  front line professionals in providing safer maternity care and improving outcomes for mothers and babies.


1.     Kirkup B. The Report of the Morecambe Bay investigation. London: The Stationery Office, 2015.

2.      GOV.UK. (2016). New ambition to halve rate of stillbirths and infant deaths. [online]

3.      NHS England (2016). Saving Babies Lives Care Bundle [online]

4.      NHS England (2018) » NHS action plan can prevent over 600 still births a year says NHS England. [online]

5.      NHS England (2019). Saving Babies Lives Care Bundle Version Two. [online]

6.      Michael Magro (2017) Five Years of Cerebral Palsy Claims: A thematic review of NHS Resolution data 

7.      RCOG (2018). Each Baby Counts Report 2018. [online]

8.      Healthcare Safety Investigation Branch. (2019). HSIB’s maternity investigation programme completes rollout into 130 NHS trusts. [online]

9.      St Georges Fetal Monitoring Team Wins National Award

10.  Liberati, E., Tarrant, C., Willars, J., Draycott, T., Winter, C., Chew, S. and Dixon-Woods, M. (2019). How to be a very safe maternity unit: An ethnographic study. Social Science & Medicine, 223, pp.64-72.

11.  Baby Lifeline (2018). Mind The Gap 2018 – Investigation into Maternity Training. [online]

12.  Health Education England (2016). Maternity Safety Transformation Fund Evaluation [online]


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