Baby deaths: Report looks into reasons why Shropshire has above average neo-natal mortality rates

Leaders at the Shrewsbury and Telford Hospitals Trust (SaTH) called in the Royal College of Physicians to review neonatal mortality in from 2021 to 2022 as a follow up to the Ockenden Review of Maternity Services. The report was received earlier this year but has just been published this week.

Some 18 families touched by neo-natal deaths have had their cases reviewed, providing insights into standards of care at SaTH. Reviewers found examples of excellent care and poor care but nothing overall that can explain the above average mortality rates among neo-natal babies.

Dr John Jones, Executive Medical Director for The Shrewsbury and Telford Hospital NHS Trust, said: “Our neonatal teams care for hundreds of very unwell babies through the early critical days of their lives.

“We owe it to them and their families to give the best care. We wanted to understand how our services could be improved, and anything we could do to reduce the above-average perinatal mortality rates in the trust and across the West Midlands.

“The review team did not identify evidence to indicate that the quality of care provided to babies by the neonatal service was substandard or directly contributing to the unit's outlier status in terms of perinatal mortality.

“However, although they described examples of good care, there were also examples of poor care that should have been significantly better. We apologise wholeheartedly for this.

“We have written to each of the 18 families whose baby or babies’ care was reviewed and have begun meeting with them, in person, to answer any questions and to offer support.

“We are grateful for their time and willingness to engage with us as we seek to improve our services wherever possible.”

A report is due to be considered at a meeting of the trust board later this week.

“Neonatal mortality at SaTH cannot be considered in isolation to neonatal mortality across the region,” the review states.

It thinks that there is a need to investigate social factors like poverty and ethnicity.

The West Midlands has the highest infant mortality in England

The West Midlands as a whole also has the highest infant mortality in England with 5.6 deaths per 1,000 live births and this has been the picture since the year 2000.

The trust say that invited reviews are best practice and demonstrate our desire to maintain transparency and to learn.

Every year around 5,000 babies are born at the Trust (SaTH) with the Neonatal team at The Princess Royal Hospital, Telford, caring for hundreds of premature or unwell babies through the early, critical days of their lives.

Some 250 babies each year need neonatal care at SaTH and in the years 2021-2022 some 18 families were affected by it.

Although rare, very sadly some of these babies do not survive beyond 28 days after birth.

SaTH’s neonatal team works as part of a network of hospitals in the West Midlands.

The most unwell babies, or babies with very complex needs, are transferred and cared for by specialist hospitals in the network, or hospitals with larger neonatal intensive care facilities.

Neonatal mortality in the West Midlands is higher than the national average

Through data received each year, the trust is aware that its neonatal mortality (babies - who sadly die within 28 days of birth) is above the national average.

Neonatal mortality in the West Midlands is also higher than the national average, and this has been the case for a number of years.

The trust received the report and its findings in September 2024 and has published them today.

The review highlights the need to investigate the drivers underpinning this data, including social determinants, health inequalities and ethnicity factors.

Giving everyone the best start in life, through a focus on prevention, is a priority for the Trust and the wider health and care system.

The review’s findings will be discussed at the Trust Board meeting on Thursday November 14. The paper is available on the trust website www.sath.nhs.uk

Data for The Shrewsbury and Telford Hospitals NHS Trust (SaTH) has shown, for a number of years, that neonatal mortality for babies born at the organisation has been more than five per cent above average when compared to similar Trusts and Health Boards.