The UK is one of the safest places in the world to give birth so it is heartbreaking when a poor outcome turns a happy event into family tragedy. In a major new initiative, the Royal College of Obstetricians and Gynaecologists (RCOG) is collecting data about perinatal deaths and severe brain injuries caused by incidents during labour so that lessons can be learned and shared. Project team member, Dr Edward Prosser-Snelling, calls the Each Baby Counts initiative ‘one of the RCOG’s biggest but most worthwhile challenges’.
Between 500 and 800 babies each year in the UK die or are left with serious disabilities as a result of incidents in intrapartum care, according to the RCOG.
If these numbers seem vague, it is because there has, until now, been no central source of information about intrapartum-related perinatal deaths and injuries. And without a national picture, there has been no opportunity to identify common risk factors, learn from what went wrong and apply the lessons in maternity units across the country.
As Dr Edward Prosser-Snelling, recalls: “We didn’t know the scale of the problem but there was a sense within the College that numbers of intrapartum-related stillbirths and perinatal deaths were higher than we would like and we weren’t doing as well as other regions, especially Scandinavia, something the current maternity review is picking up on too. The President and the two principal investigators, Zarko Alfirevic and Alan Cameron, felt that there was an opportunity to make a difference.”
“The ambitious target of the Each Baby Counts project is a 50% reduction by 2020 in incidents during term labour which lead to stillbirth, neo-natal death and severe brain injury.”
The ambitious target of the Each Baby Counts project is a 50% reduction by 2020 in incidents during term labour which lead to stillbirth, neo-natal death and severe brain injury diagnosed in babies in their first week of life. To achieve its goal, the RCOG is pooling the anonymised results of local investigations across the UK, carrying out thematic data analysis and making evidence-based recommendations to reduce avoidable harm.
A broader perspective is of critical importance and echoes the principles established by An Organisation with a Memory, the ground-breaking investigation into patient safety in the NHS1. Dr Prosser-Snelling says: “An individual maternity unit might carry out a root cause analysis or make risk recommendations and people will remember for six months but then inevitably they will move on. We want to capture this information at a higher level and make lasting cultural changes.”
Every NHS and private maternity service in the UK has nominated a Lead Reporter for Each Baby Counts. They are responsible for reporting eligible cases when they occur via an online data collection system, and will be the main contact point in case of queries from the project team. Dr Prosser-Snelling and his colleagues have already started to analyse more than 100 cases which have been reported since the collection process began in January 2015.
They hope to make a preliminary report in the next few months and there will be an annual report summarising the main themes which emerge from the analysis, as well as shorter and more frequent safety bulletins and newsletters. The team is also carrying out a review of existing literature and guidance to inform its reports and help ensure future research is focused where it is most needed.
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As a senior registrar in obstetrics and gynaecology, Dr Prosser-Snelling stresses that mistakes are rare but he has seen at first-hand what can go wrong and the devastating consequences. He reflects: “The cerebral palsy cases caused by lack of oxygen are rare, but tragic for everyone: the child who has a life-long disability; the parents who had every expectation of a normal birth and are now faced with a life-changing responsibility; the siblings who will lose their parents’ attention; and the grandparents.”
He also estimates that the cost of providing round-the-clock care for the lifetime of a child in this situation is around £5million but frequently in excess of this. If the Each Baby Counts project is successful, the funds currently used to compensate patients could, he believes, be invested in patient care instead.
The RCOG has attracted support from patient groups, as well as obstetricians, neonatologists and midwives but Dr Prosser-Snelling hopes that all clinicians will support Each Baby Counts. For example, he urges junior doctors to be honest and open if they are asked to provide a statement for a serious incident review.
“We are not asking people to do anything they are not already doing,” he comments. “Part of the culture change we want is for every investigation to be a process of learning rather than punishment so that reviews include sufficient detail and are of high quality. That requires clinicians to participate honestly and freely and managers to ensure a just culture in their department.”
Dr Prosser-Snelling is excited to be part of the project team for Each Baby Counts: “It’s a great opportunity to be at cutting edge of a something with the potential to improve outcomes for women and babies. It will be wonderful if we can help put in place evidence-based measures and care bundles that genuinely save lives.”
Dr Michael Devlin comments:
The MDU wanted to draw the Each Baby Counts project to the attention of members because it is a good example of how data can be used to understand the underlying causes of harm arising in childbirth and to share this learning for the common good. The RCOG have made reporting simple, which should help to ensure that complete and comprehensive data is obtained.
The RCOG’s initiative is likely to touch a chord with many healthcare professionals, even if they have not worked in a maternity unit since qualifying, as many will help to care and support children and their parents affected by a problem in childbirth. And, as many groups of doctors such as GPs and paediatricians may face questions from families about Each Baby Counts, we are pleased to help increase awareness of the project.
All doctors have a professional responsibility to take part in clinical governance procedures that are related to their clinical practice. Sometimes this will be at a local level, such as root cause analysis, but it is important to be familiar with national initiatives, such as NHS England’s National Reporting and Learning System, and national databases on surgical or treatment outcomes.
You might also like to sign up to the five pledges underpinning the Sign up to Safety campaign, which is one of a number of initiatives to change NHS safety culture so it is more open, honest and allows learning from patient safety incidents.
The success of Each Baby Counts will ultimately depend on the extent to which every NHS organisation and healthcare professional commits to putting safety first and embraces a culture that allows collaboration and learning.