That is more than 500 babies who have died or been severely brain damaged or physically injured in circumstances that were avoidable, causing terrible grief and changing the lives of families forever.
Each Baby Counts is the RCOG's national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. Reviewers are asked to upload technical reports on each case including clinical opinion whether different care would have made a difference to the outcome.
In the most recent analysis, 508 (74 per cent) of the babies were identified as having an outcome where at least one reviewer was of the opinion that different care might have made a difference.
Of equal worry is that despite RCOG repeatedly highlighting the critical condition of maternity services in UK hospitals, this figure has not materially changed over the three reports since 2017 for which it has been calculated, nor have the factors contributing to poor care, despite recommendations specifically designed to address them.
Reviewers are asked to indicate what they consider the critical contributory factors influencing the outcome. The five most common themes were cardiotocography (CTG) and blood sampling, risk recognition, team communication issues, individual human factors, and education/training.
What is clear from this report and from our own experiences of running maternity negligence claims on behalf of families affected, is that rarely is one single factor behind the tragedy of the death of a baby or serious injury.
The report clearly states that care provision is rarely carried out by single individuals in isolation. A sufficiently staffed workforce and availability of equipment are essential to excellent care, but if they are not in place then risk of error by the workforce and incorrect use of equipment increases. In other words, failings are inter-linked and compounded by poor communication, lack of training and staff shortages.
The RCOG recommends a shift focus from ‘what’ needs to change to ‘how’ that change can be delivered because the workforce behind maternity is complex and there is an increasing focus now placed on culture and leadership, while also recognising that no amount of leadership can make up for lack of staff.
And as the report acknowledges, no amount of training can support someone to deliver care in a particular way if the resources to undertake the task are not present.
Fieldfisher's maternity negligence team fully supports the RCOG's reporting of maternity services and any recommendations to improve care to better support mothers and babies and to reduce critical failings.
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