• RCOG study found more than 550 babies born in 2015 may have had a different outcome
  • Only a third of local investigations involved families or patients
  • Quarter of local investigations were not good enough to assess quality of care

Hundreds of babies who died during or shortly after birth or who suffered serious brain damage could have had a different outcome if their NHS care had been different, a major new study has concluded.

The Royal College of Obstetricians and Gynaecologists examined more than 1,100 births in 2015 from all NHS trusts where babies were delivered. It was the first detailed study of its kind in the UK. The report identified serious flaws in local investigations by trusts and said more than 550 babies potentially suffered avoidable harm.

The report, published today, has recommended trusts make changes to their maternity services including an emphasis on ensuring staff are properly trained in foetal heart rate monitoring; that staff train and work as multidisciplinary teams; and that all units are trained in human factors, specifically situational awareness training to help staff cope during complex cases.

An investigation by HSJ last month identified concerns around the ability of some midwives and doctors to interpret foetal heart rates, and lack of training and teamwork. There have been hundreds of clinical negligence claims, which costs the NHS almost £500m a year.

Co-principal investigator, Professor Zarko Alfirevic, a consultant obstetrician at Liverpool Women’s Hospital, said: “Problems with accurate assessment of foetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting foetal heart rate patterns, have been cited as factors in many of the cases we have investigated.

“The focus of a local investigation should be on finding system-wide solutions for improving the quality of care, rather than actions focusing only on individuals.”

Each Baby Counts is a national quality improvement project launched by the RCOG in October 2014. It aims to halve the number of babies who die or are left severely disabled because of preventable incidents during labour by 2020.

The RCOG identified 1,136 babies born in 2015 meeting its criteria to be included in the Each Baby Counts review, with 727 cases and local reviews being examined to investigate the quality of care and learning from any errors. A full report and data from the study is due to be published later this year.

In the 727 cases looked at by the RCOG, experts found:

  • A quarter of the local investigations were not thorough enough to allow an assessment of the quality of care.
  • In 76 per cent of the cases – more than 550 babies – where was sufficient information to draw conclusions about the quality of care, at least one reviewer concluded the baby might have had a different outcome with different care.
  • Only 34 per cent of local reviews invited parents and families to be involved.
  • External reviewers were involved in 9 per cent of the local reviews.
  • Where clear actions were recommended by local reviews, 23 per cent were aimed solely at individual members of staff.

The report recommended:

  • Women should have a formal foetal risk assessment on admission regardless of the place of birth to determine the most appropriate monitoring method.
  • NICE guidance on when to switch from intermittent to continuous heart monitoring should be followed, with staff tasked with interpreting heart rate monitoring having documented evidence of annual training.
  • All members of the clinical team working on the delivery suite need to understand key principles of maintaining situational awareness to ensure the safe management of complex situations.
  • Senior members of staff should maintain a “helicopter view” of activity on delivery suites
  • Clinical staff should be empowered to seek out advice from a colleague not involved in the situation.
  • Safety huddles with clinical leaders should be used when managing complex situations involving the transfer of care or multiple specialties so that patient safety relevant information is shared.