PROJECT PROFILE


Each baby counts


Solicitor Bertie Leigh sets out the aims of an ambitious project to reduce avoidable injury and death in labour


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ACH year in the UK between 500-800 babies die or suffer severe brain injury during birth. Many of these tragedies


occur not because the babies are born too soon or too small, or because they have a congenital abnormality. It is when something goes wrong during labour. Recently the Royal College of Obstetrics


and Gynaecology (RCOG) launched a project – Each Baby Counts – that hopes to see a 50 per cent reduction in the number of babies who die or are leſt severely disabled as a result of adverse incidents occurring during term labour. Te RCOG is proposing to provide a central repository of serious untoward incident (SUI) reports on all stillbirths at term and other serious obstetric incidents. Tese will be analysed and the lessons learned extracted. A network of local reporters will be


set up in hospitals – modelled on the structure of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) – to collect the reports and provide a two-way chain of communication to drive improvement. Each Baby Counts will have a two-pronged approach: it will seek out evidence-based interventions via


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a systematic review of the literature and provide a central analysis of SUI reports to look for common themes, feeding these back to trusts.


A simple approach Like all really good ideas, Each Baby Counts is both simple and ambitious. It is simple because the reports are comparatively short, can be easily collected and the organisation necessary to provide central peer review need not be complicated. It is ambitious because these reports collect and review serious clinical mishaps – cases where there is enormous opportunity for learning from experience. Tere needs to be change because SUI reports are at the moment very patchy in quality, if indeed they are completed at all. SUI reviews should take place promptly,


when memories are fresh and the enthusiasm to learn from an incident is at its highest. Tey need cost very little because they are all done in-house, capitalising on a shared determination to learn from experience. Management should try to ensure that there is an atmosphere of minimal blame.


No other review provides feedback that


is either local or prompt. Te confidential enquiry reports from MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) and NCEPOD come long aſter the event and the lessons are generic, in the sense that they are nationwide. Tey are admirable for giving advice to the profession about how to deliver obstetrics more safely, but a long way from being tailor-made to each hospital’s problems. By the time the reports are received, the staff involved have oſten moved on. Te same is true of litigation. Characteristically, the NHSLA does not receive claims arising from events within a year or two. Many of the cases I see do not get an SUI


investigation when they clearly should. If the only result of Each Baby Counts is to emphasise that SUIs are necessary and to create a cadre of local reporters who will advocate for that proposition in each hospital, it will be useful.


Questions of quality Te NHS Ombudsman has recently reported that SUI reports are


SUMMONS


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