On 19 November, the MBRRACE-UK released its “Perinatal Confidential Enquiry Report 2015”. The pregnancy notes of 133 stillbirths following a full term pregnancy were reviewed, of which 85 were considered in detail by a panel of clinicians against national care guidelines. It suggests that an improvement in quality of care provided by hospitals could save the lives of hundreds of babies every year.
The enquiry found the following missed opportunities: -
- In 50% of antepartum term stillbirth, improvement in the quality of care may have made a difference to the outcome.
- Two thirds of women deemed at risk of diabetes during pregnancy were not offered the necessary testing. It suggests monitoring the pregnancies more closely could potentially save the baby.
- In two thirds of the cases reviewed, the hospital and staff did not follow the national guidance for screening and monitoring the growth of the baby adequately.
- Nearly half of the expectant mothers raised concerns with staff at their local maternity units that their baby’s movements had slowed, changed or stopped. In 50% of these cases, there was a lack of investigation into the cause of this, staff misinterpreted the baby’s heart trace or a there was a failure to respond appropriately to other worrying factors.
- In 25% of cases, documentation was provided indicating an internal review had taken place following the stillbirth. This review allows hospitals to understand whether the baby’s stillbirth could have been prevented and to learn lessons for the future. The quality of these reviews was deemed highly variable.
- There is a good standard of bereavement care provided to parents immediately following the stillbirth including the opportunity to create memories of their baby.
This enquiry has been described as alarming by Judith Ebela, Chief Executive of SANDS after it follows a similar report produced 15 years ago criticising the antenatal care provided by hospitals. This suggests that little has been learnt in the interim and not enough is being done to prevent babies from dying.
There are no words that can truly express how devastating a stillbirth is to the parents and families. So, what is being done to address every parents’ worst nightmare?
Last week, Jeremey Hunt, Health Secretary announced a “new ambition” to reduce the rate of stillbirths, neonatal and maternal deaths in England by 50% by 2030. This will include brain injuries suffered by a baby during or soon after a birth. As part of this new commitment, the government will work alongside consultants, midwives and other experts to make England the safest place to have a baby. They aim to ensure the best care and practice is provided and applied consistently across the NHS and that lessons are learnt from every stillbirth and neonatal death.
Some of the governments initiatives are as follows: -
- Trusts will receive a share of £4 million to invest in quality equipment and necessary training to improve the outcome for mother and baby. This includes £2.24 million to purchase monitoring and training equipment to improve the safety, such as cardiotocography (CTG) equipment to monitor babies’ heartbeat and quickly detect any problems.
- Maternity services will be approached to come up with initiatives that can be widely adopted across the country. Staff will have the appropriate training to enable them to identify the risks and symptoms of perinatal mental health.
- A further £500,000 is to be invested in developing a new system for staff to internally review and learn from every stillbirth and neonatal death.
- Over £1 million will be invested in training packages to make sure staff have the skills and confidence they need to deliver world-leading safer care.
In some cases a failure in care and testing by hospitals resulting in stillbirth or a brain injury can result in a claim for negligence. It is critical that all stillbirths are fully investigated so hospitals and staff can learn from each to prevent this happening to other families.
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