RCOG highlights proof babies could be saved with better care | Fieldfisher
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RCOG highlights proof babies could be saved with better care

Mark Bowman
The good news is that maternity initiatives introduced by the government in 2015 may have begun to bite as the number of stillbirths fell for the first time in a decade. The bad news is that too many babies still die because of inadequate maternity care.

The positive study, out of the University of Leicester, reports that, having been static for 10-15 years, the number of stillbirths in the UK fell from 3,252 in 2014 to 3,032 in 2015. Although this is an improvement, rates vary widely across the UK, which still ranks badly compared to other European countries. To meet targets to halve stillbirths by 2030, much more needs to be achieved, and quickly.

In the same week as the University of Leicester study, the Each Baby Counts report from the Royal College of Obstetricians and Gynaecologists shows that of more than 700 cases of neonatal deaths and brain injury investigated during 2015, a shocking three in every four babies may have been saved had they received different care. That is, 75 per cent of tragedies could have been prevented.

Yet again, this is a story of serious problems assessing and understanding foetal monitoring, particularly CTG traces, and the inability of maternity staff to react to abnormal readings.

A high proportion of our birth injury cases involve the devastating consequences of mistakes around CTG readings, and the facts make depressing reading.

Jane Weakley had two recent, separate cases where midwives failed to react to CTG readings that clearly showed a baby was in distress.

One involves the North West London Hospitals NHS Trust, where midwives failed to act when the baby's heart rate dropped during labour. The CTG was pathological yet midwives failed to call for medical review and allowed the labour to continue and for the baby to be starved of oxygen. The child, AP, has cerebral palsy: she can't walk unaided, struggles to feed herself, has epilepsy, very limited communication and reduced eyesight, leaving her needing round-the-clock care for life.

In a similar case, SB versus The Queen Elizabeth Hospital King's Lynn Trust, midwives failed to realise that the CTG was recording the mother's heart and not the baby's, which meant they thought that the baby was in good condition during labour. Had the midwives checked the maternal pulse, as they should have done, they would have realised their mistake and could have repositioned the CTG transducer revealing a pathological trace. SB was born in very poor condition and has severe cerebral palsy, is tube fed and requires 24-hour care.

Arti Shah acted for the parents of Bobby Goddard who was born in very poor condition when midwives failed to react to a suspicious trace. His mother Kate was eventually given an emergency C-section but it was too late to save Bobby. His brain had been starved of oxygen and could not breathe on his own. The heart-breaking decision was made to withdraw treatment. Bobby's father, Ian, was diagnosed with suffering from PTSD following his son's death. Arti is currently working on three other cases where CTG traces were misinterpreted.

1. C admitted to the labour ward, waters broken and induced but long delay before delivery. An untoward CTG trace with material decelerations indicated the foetus was in distress and there ought to have been immediate delivery. 

2. B monitored using intermittent auscultation only (no CTG used). Category 1 emergency ventouse delivery performed after pre-terminal trace noted by fetal scalp electrode. Midwife to undergo further training on CTG monitoring and when it should be commenced.

3. Failure to act on a pathological trace, after which CTG was subsequently stopped despite the abnormalities identified. Baby girl now suffers cerebral palsy. The case is further complicated by the CTG trace having been lost by the hospital.

In one of several birth injury cases, Mark Bowman won settlement for the parents of baby K who was born at Darent Valley Hospital in 2007. K was born with catastrophic brain injury three hours after a trace was deemed pathological. She now suffers four-limbed cerebral palsy and epilepsy.

In a similar case against Frimley Health NHS Foundation Trust, Mark achieved a multi-million pound settlement on behalf of L, who lives with dyskinetic (involuntary movement) quadriplegic (affecting all four limbs) cerebral palsy. She is unable to stand or walk unaided and is dependent on a wheelchair. L has mild cognitive deficits but has been able to attend mainstream school, albeit with one to one support.

She is aware of her surroundings, and more importantly of her disabilities and the limitations they place on her. She hopes to one day qualify for the Paralympics as a showjumper.

The evidence from the ROCG report is shocking and likely deeply distressing for the families of babies affected or who died as a result of these failures in care. The hope now is that proper focus on improving vital care will prevent future tragedies.

The Each Baby Counts report recommends:

  • all low-risk women are assessed on admission in labour to see what foetal monitoring is needed
  • staff get annual training on interpreting baby heart-rate traces (CTGs)
  • a senior member of staff must maintain oversight of the activity on the delivery suite
  • all trusts and health boards should inform the parents of any local review taking place and invite them to contribute.