Baby death reviews not up to standard, says report

The first annual report from the Royal College of Obstetricians and Gynaecologists' (RCOG) "Each Baby Counts" initiative has concluded that more "robust and comprehensive" local reviews are urgently needed to ensure lessons can be learnt and improvements made.

Shropshire couple Richard Stanton and Rhiannon Davies, who fought a seven-year battle with health chiefs over an investigation into their newborn daughter's tragic death, have said their example is a case in point.

The Each Baby Counts initiative is a national quality improvement programme aiming to halve the number of such tragic events by 2020 by taking lessons from all local investigations following its launch in October 2014.

So far it has looked at the cases of 921 babies reported to the programme in 2015, of which 654 were classified as having severe brain injuries, 147 as early neonatal deaths and 119 stillbirths that occurred during term labour.

Of 610 reports which have been completed 566 had a local investigation of some kind but 27 per cent of those were classed as poor quality by the RCOG as they did not contain sufficient information.

Of those that passed the initial quality checks, 39 per cent contained no actions to improve care or only made recommendations solely focused on individual actions rather than reviewing systems or processes.

Although 96 per cent of reviews were carried out by multi-disciplinary teams only seven per cent included an external expert.

In a quarter of cases the parents were not made aware that an investigation was taking place, and parents were invited to contribute to the investigation in only 28 per cent of cases.

Baby Kate Stanton-Davies died just six hours after being born at the midwife-led unit at Ludlow Hospital in 2009 and the initial investigation was carried out that year, but mother Rhiannon said it showed similar "local review" problems that the family had to fight for years to have looked at again.

In April this year the findings of a fresh independent review were published criticising Shrewsbury and Telford Hospital NHS Trust for failing to properly investigate the first time.

SaTH chief executive Simon Wright apologised unreservedly to the family and said "significant steps" had been taken to ensure improvement, while Professor Peter Latchford, chairman of the trust's board, told the couple he was "ashamed" of the way health bosses behaved towards them in the aftermath of Kate's death.

The author of this year's report, maternity services expert Debbie Graham ruled the trust failed to investigate Kate's death, failed to hold staff to account and failed to address concerns raised by the couple.

Rhiannon said she felt there was "no appetite for learning in maternity, and no appetite for admitting when things go wrong," and said they faced a long battle to get an official inquest into why Kate died.

She said: "When the jury-led inquest was finally held in 2012, thanks to our solicitor Ian Cohen, it began unravelling the truth about the fact Kate's death was entirely avoidable.

"We took our case to the parliamentary and health service ombudsman and they upheld it, detailing that the hospital trust was guilty of Kate's avoidable death and of maladministration."

She said the original 2009 investigation was carried out by a colleague of one of the midwives involved and was deemed by NHS England last year as "not fit for purpose", leading to this year's independent report which harshly criticised the first for containing errors and omissions.

Professor Alan Cameron, RCOG vice president for clinical quality, said the new Each Baby Counts report showed the need for more "robust and comprehensive" reviews. He said: "We need to move to a more standardised national approach for carrying out these investigations to improve future care. The focus of a local investigation should also be on finding system-wide mechanisms for improving the quality of care, rather than individual actions."

Janet Scott, research and prevention lead at Sands, the stillbirth and neonatal death charity, said: "We have been calling for a robust and effective review process for some time, including parental involvement in local investigations."