The Royal College of Obstetricians and Gynaecologists has just published its report Each Baby Counts. In this blog Henry Dyson discusses his experience as a member of the medical negligence team and how basic failures can lead to catastrophic failures
The Royal College of Obstetricians and Gynaecologists (RCOG) aim is to reduce the number of babies that die or who are severely injured by preventable incidents by half by 2020 by learning lessons from data gathered for all births during 2015.
There were 723,251 babies born at term in the UK. The report found that 1136 cases qualified into the study but of those cases there was only enough information on 727 cases for inclusion into the study. This means that there was insufficient information in more than 400 cases, a worrying statistic.
Of the 727 cases studied the authors of the report found that parents were not involved in about two thirds of the reviews. Again a worrying statistic that could suggest that hospital Trusts were not sharing information with nearly 500 parents.
The report found that only 9% of local reviews involved external panel membership. The report recommends that future reviews must not share these deficiencies.
The report notes that while the UK is one of the safest places to give birth, lessons must be learnt, particularly with regard the use a Cardiotocographic (CTG) monitoring of the fetal heart during labour.
This is not a new issue and the NHS Litigation Authority (now NHS Resolve) produced a report in October 2012 Ten Years of Maternity Claims where it found that errors with regard to CTG use and interpretation were the common themes and that lessons were not being learnt.
Our experience of birth injury accords with the conclusions of this new report in that basic failures are being repeated and these are resulting in tragic outcomes for hundreds of children each year and an enormous financial burden on the NHS.
We hope that the RCOG’s initiative is successful.