Baby deaths and disability blamed on midwives’ failings
THREE in four newborns who die or are left brain damaged in maternity units might have been saved with the right care, a “devastating” national audit reveals.
The investigation – the first to probe every such death in a single year in detail – follows warnings from coroners that tragedies are being repeated because it is “commonplace” for midwives to qualify without training in the use of basic equipment.
The study by the Royal College of Obstetricians and Gynaecologists examined 1,136 births in 2015 which ended in neonatal death, severe brain injury or stillbirth after a pregnancy came to term. In 76 per cent of properly documented cases, the baby might have been saved from death or disability had different action been taken.
An average of six errors lay behind each case, experts said – with failings in monitoring of babies’ heart rate among the most common.
Last night charities said the findings were “shocking” and “inexcusable”.
The college set out plans to overhaul standards, with annual training for all staff who interpret scans and formal risk assessment of every woman in labour to ensure proper monitoring.
The report said that in one in four cases, record keeping was so poor that experts were unable to draw conclusions about the quality of care.
It follows a string of deaths of babies
whose hearts had not been properly monitored during labour, and warnings that Britain has one of the worst rates of stillbirth in the developed world. In recent months, coroners have urged regulators and hospitals to take urgent action to ensure midwives and doctors are properly trained in interpreting foetal scans.
Prof Lesley Regan, RCOG president, said: “It is a profound tragedy whenever a death, disability or illness of a baby results from incidents during labour. The emotional cost to each family is incalculable and we owe it to them to properly investigate what happened and ensure the individuals and the healthcare trusts involved take the steps needed to avoid making the same mistakes again.”
Since 2004/5, the value of claims against NHS maternity units for brain damage and cerebral palsy has tripled, fuelling maternity negligence claims of more than £1.2 billion in 2015-16.
Janet Scott, the research and prevention lead at Sands, the stillbirth and neonatal death charity, said she was “deeply shocked” by the unacceptable rate of harm revealed in the report, describing the failure to properly review the deaths as “inexcusable”.
Caroline Lee-davey, the chief executive of Bliss, the premature and sick baby charity, said the findings were “devastating”.
“Every stillbirth, neonatal death and life-long injury is a tragedy for the family affected, whose hopes and dreams for their baby are changed in an instant,” she said.
Dr Sarah Mcmullen, the head of knowledge at the NCT, said “dangerously low staffing levels” were putting women and their babies at risk.
Last night Jeremy Hunt, the Health Secretary, restated pledges to improve safety in maternity units.
“I want to make the NHS one of the safest places in the world to give birth by halving rates of stillbirth, deaths in childbirth and brain injuries by 2030,” he said.