Each Baby Counts Progress Report reveals extent of birth-related harm to babies

The latest progress report by the Royal College of Obstetricians and Gynaecologists’ (RCOG) maternity quality improvement programme, Each Baby Counts, has revealed that in 2016, in the UK, 1,123 term babies were severely brain damaged at birth, stillborn or died within the first week of life. For 674 of these babies, the Each Baby Counts reviewers believed that the outcome would have been different if they had received different (i.e. better) care.

No improvement in levels of harm to babies from 2015 to 2016

The statistics are not good. In fact, the figures clearly demonstrate that in 2016 there was no significant improvement in the levels of harm suffered by babies compared with those born in 2015.

Of the 696,370 term babies born in 2016, 1,123 fulfilled the RCOG’s criteria for reporting to Each Baby Counts (compared with 1,136 in 2015). That’s one in every 620 babies in 2016, compared with one in 635 in 2015.

The criteria for Each Baby Counts eligibility are that the baby: 

• Was born at term (either at or over 37 weeks gestation); and either
• Suffered an intrapartum stillbirth, i.e the baby was alive at the start of labour but born without signs of life; or
• Died within the first week of life (early neonatal death); or
• Was diagnosed with severe brain injury in the first seven days of life and had:
  • grade III hypoxic ischaemic encephalopathy (HIE);
  • active therapeutic cooling;
  • decreased central tone + comatose + seizures.

Of the 1,123 eligible Each Baby Counts babies in 2016:

• 124 were stillborn (compared with 126 in 2015);
• 145 babies died in the early neonatal period (compared with 156 in 2015); and
• 854 babies suffered severe brain injuries during labour at term (compared with 854 in 2016).

Different care might have led to a different outcome for 71% of injured babies

The reviewers believed that different care might have led to a different outcome for 71% of these babies, a figure only marginally better than the 74% in 2015, and which the report quite rightly states remains too high.

As we know at Boyes Turner from our own experience of brain damaged baby cases, there is rarely a single cause for any serious injury. The report identified an average of seven critical contributory factors for each of the babies whose outcome could have been improved with better care.  

In commenting on the common causes of harm and making recommendations for improvement, the report deliberately avoided commenting further on recurring factors, such as errors with fetal monitoring and human communication which were analysed and discussed in its previous report. Given the overall lack of improvement in the statistics, and Boyes Turner’s own experience from handling large numbers of severe birth and neonatal injury cases, it would be surprising if the Each Baby Counts recommendations for improvement in these areas had been implemented sufficiently at local level by 2016 to result in measurable change.

Guidelines not followed in 45% of avoidable harm cases

This time, the report focussed on other areas needing improvement, including obstetric anaesthetic care (with recommendations directly echoing those of the Each Baby Counts Anaesthetic Report) and lack of adherence to guidelines.

In nearly half (45%) of the 674 cases where inadequate care might have affected the outcome, national guidelines, such as the National Institute for Health and Care Excellence (NICE) Intrapartum Care clinical guideline CG190, and locally agreed best practice hadn’t been followed.

The reasons for not following the guidelines included:

• gaps in training;
• failing to recognise problems;
• workload and staffing levels; and
• local guidelines not following up-to-date or best practice.

The resulting recommendations include:

• that in times of high activity and increasing workloads, escalation policies and a culture exists in which maternity staff in all disciplines and levels feel able to inform senior members of staff, management and consultants of their concerns;
• the consultant obstetrician is always informed when activity levels are high;
• the labour ward coordinator must retain an overview position and not have direct responsibility for caring for women antenatally, intrapartum (during birth) or postnatally.

In relation to guidelines:

• there must be a clear policy and allocation of resources and staff time to ensure that local guidelines are kept up-to-date with national guidance, with all deviation from national guidance clearly documented and regularly reviewed.
• The tendency over time for practice to migrate away from guideline-based practice must be recognised and guarded against.

Reviews should involve parents, anaesthetists and neonatologists

Each Baby Counts continues to call for improved reviews (from which better learning can take place) in the aftermath of a birth-related injury, recommending that all reviews involve an anaesthetist and, if appropriate, a neonatologist, and follow a collaborative multidisciplinary approach.

Whilst minor improvements in the quality of reporting incidents to Each Baby Counts were noted, sadly, in 2016 almost a quarter of the parents of babies born stillborn, brain damaged or suffering early neonatal death were still not invited to be involved or even made aware that investigation reviews were taking place into the circumstances leading to the tragic loss or injury to their child.

The Each Baby Counts’ Progress Report calls for urgent improvements in the culture, resourcing, practise and reviewing of maternity care, based on what it has called the ‘hard facts’ that 2016’s cohort of injured babies presents to local, national and governmental maternity providers.

Individually, each of these lost or damaged children leaves a family devastated by tragedy and, in the brain injured cases, faced with the hardship associated with caring for a much loved, severely disabled and life-long dependent child. Knowing that the outcome would have been avoided but for inadequate care makes the loss all the more unbearable and the NHS’s obligation to explain, apologise, compensate and learn non-negotiable.  

If you are caring for a child with cerebral palsy or other birth-related neurological disability, contact us by email on cerebralplasy@boyesturner.com.