In November 2018, the Royal College of Obstetricians and Gynaecologists (RCOG) published the results of local investigations into stillbirths, neonatal deaths and brain injuries occurring during term labour. The report was produced to share lessons, understand the bigger picture, and to prevent babies from dying or sustaining brain injuries in the future.
The programme reviewed 1123 babies born in 2016. Of those, it found that 11% were stillbirths, 13% were early neonatal deaths, and 76% suffered severe brain injuries. Overall, it found that for around 71% of babies reviewed, the outcome may have been different with different care.
The main themes identified where improvements could have been made were:
– Failures by health professionals to identify or act upon relevant risk factors;
– Issues related to monitoring babies’ wellbeing with CTG traces and blood sampling;
– Education / training issues;
– Local guidelines not being updated in line with national guidance;
– Workload capacity. For example, untrained staff being used as substitutes for trained midwives because their supervising midwives had additional women to care for. Another example identified was labour ward coordinators compromising their ability to maintain situation awareness and to deliver high quality care because they were assisting emergency deliveries instead.
– There were also instances when emergency situations were rightly picked up by midwives, but there was no clear escalation system, so patients were not reviewed urgently as required.
– Miscommunication between hospitals was also contributing to poor outcome.
Ultimately it is hoped that by identifying the lessons to be learned, care will also improve.
Our specialist medical negligence team here at Girlings Personal Injury Claims has extensive experience dealing with claims arising from errors during labour. Three of our team members are accredited with the Foundation for Infant Loss. Please do not hesitate to contact our sensitive team should you have any concerns surrounding your maternity care.