- June 22, 2016
- By Dr Jock Mackenzie
- 0 comments
Each Baby Counts
Each Baby Counts is the Royal College of Obstetricians and Gynaecologists’ (RCOG) national quality improvement programme aimed at reducing the number of babies who die or who are left severely disabled as a result of incidents occurring during term labour, click here.
On its webpage, the RCOG explains: “In the UK, each year between 500 and 800 babies die or are left with severe brain injury – not because they are born too soon or too small, or have a congenital abnormality, but because something goes wrong during labour. The RCOG does not accept that all of these are unavoidable tragedies, and with the Each Baby Counts project we are committed to reducing this unnecessary suffering and loss of life by 50% by 2020”.
The project has been working since January 2015 collecting local risk management reviews and studying them for outcomes.
It has just published (June 2016) its preliminary report, entitled “Key messages from 2015″, click here. It makes for sorry reading.
Out of 800,000 births in the UK in 2015, 921 were eligible to be reported in the programme. These figures are higher than the programmes original estimate of 500-800 per year.
13% (119) were intrapartum stillbirths, 16% (147) neonatal deaths and 71% (655) severe brain injuries. It is not clear, however, how many of these latter infants will have long term disability.
Of these 921 cases, 610 had fully completed information on the Each Baby Counts online reporting system so that complete information was available to be reviewed. Of these, 599 had a local review of some kind. 52% had some form of specific tool or methodology utilised in their review (such as Root Cause Analysis (128)), but 48% did not.
Only 7% of review panels had an external expert. This is a problem we encounter frequently in clinical negligence cases, where there has not been any independent review or analysis conducted of patient management and the result appears to be a self-serving “whitewash”.
25% of parents were not even made aware a review was being carried out and 47% were made aware but not invited to take part. In only 28% were parents both aware and invited to take part.
Of the 599 cases that had a local review, 204 investigations have been analysed by a multidisciplinary pair of reviewers at Each Baby Counts. Pretty shockingly, 27% of these 204 did not contain sufficient information to allow the care to be classified and, as such, were deemed to be of “poor quality” such that the reviewers determined that the document(s) submitted did not contain sufficient information for them to answer the question: “Would different care have made a difference to the outcome?”
Of the 150 local reviews in which there was sufficient information for a full evaluation, 32 (21%) contained no actions or recommendations and 27 (18%) had actions or recommendations which were solely focused on individual members of staff (for example, a requirement to attend further training). The report questions whether such reviews and reviewers are opting for “the easy way out”.
Health Minister Ben Gummer said the findings were “unacceptable”, click here to read more. The final report is due in 2017. It will be interesting to see what it contains and, if the trend identified in the preliminary report continues, what the government intends to do about it.