extraordinarily inconsistent. Some are high-quality learning exercises, but others fail to highlight what appear to be fundamental learning points and errors. Others are so excessively self-critical that it seems the authors have apparently lost the capacity to be fair to themselves and each other. A third group we review in litigation
also seem to be so factually flawed that we wonder if the authors ever read the clinical notes properly. Reports need to be done professionally and at the moment it is nobody’s day-job. Tere is no real training available. Tere is not enough clarity about who should do them, what materials should be assembled and what preparation the witnesses should have. A central audit could be valuable in
raising the quality of the reports. People who write them need training and guidance and Each Baby Counts will bring this to national and local attention. Constructive criticism of each report from properly informed peer review should be helpful. Te action plans that arise from SUIs are also oſten lost and poorly followed up.
SUMMER 2015
Tere are shared themes running throughout these reports that can be better identified in a centralised review. Even if the willingness to learn will be maximal in the hospital where an incident has happened, there is nevertheless a national willingness to learn from mistakes that have happened elsewhere.
A modest start At present the proposal does not involve the College receiving the clinical notes or any documentation from the Trust other than the SUI report itself. We do not know how the process will develop: experience may reveal that it is difficult for reviewers to recognise the report that is wrong in its identification of the factual matrix and that this inhibits the quality of the review. We may call for reports from the lead clinicians and a copy of the clinical notes, like NCEPOD. It may be so successful that we can justify the resources needed for such a change. Or in a few years we may recognise that the advantages of economy and speed outweigh the value of assembling the base data. It is a good idea to start modestly and see how things develop.
Te fact that Each Baby Counts is to be
the work of the profession is enormously attractive. Advice from senior obstetricians and midwives, people who have been there themselves and are concerned only to help the clinicians to do better in the future, is much more acceptable and likely to be much more constructive than advice from an external bureaucracy. It will also be much cheaper and more direct. Above all, this is an example of the
profession seizing the initiative in seeking to raise the quality of clinical care that is delivered in hospitals. We know that this combination of professional altruism and authority is one of the great resources of the NHS and we should congratulate the RCOG on finding a way to harness it in pursuit of an objective that is both simple and worthwhile.
n Mr Bertie Leigh (Hon FRCPCH, FRCOG ad eundum) is Consultant at Hempsons Solicitors and Chair of NCEPOD. He has been a legal advisor to the RCOG for 30 years and is a member of the independent advisory group to Each Baby Counts
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