NHS could have prevented 800 baby deaths in 2023
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The NHS could have prevented more than 800 baby deaths last year, a report has found.
It means that one in five babies who were stillborn or died shortly after birth could have been saved if care had been better, according to hospital data analysed by University of Oxford experts.
Half of maternity services are now rated “inadequate” or “requiring improvement” by the safety regulator, up from 38 per cent the year before, according to the second annual Saving Babies’ Lives report by Sands and Tommy’s, the baby loss charities.
It comes as a Birth Trauma Inquiry report, published on Monday, revealed widespread failings and mistakes at NHS maternity units were leaving mothers and babies with life-changing injuries amid a culture of cover-up.
Since 2018, the perinatal mortality review tool (PMRT) has been used by hospitals to understand why baby deaths occur and “consider whether issues with the provision of care may have contributed to late miscarriage, stillbirth, or neonatal death”.
The number attributed to failings by the NHS has increased every year since, with 822 of the 4,111 deaths reviewed between March 2022 and February 2023, considered as avoidable. Almost all deaths are reviewed. There were 605,479 live births in England and Wales in 2022, down by three per cent on the year before.
The figure for last year is double the one in 10 avoidable deaths that occurred in 2018 and is slightly up on the 18 per cent for last year.
Robert Wilson, head of the Sands and Tommy’s joint policy unit, said the Government’s “failure to pledge at least enough additional funds to keep pace with inflation is unacceptable and short-sighted”.
“The government has still not grasped the scale of the improvement needed to achieve its own ambitions to save more babies’ lives,” he said, adding that England was not on target to meet its aim of halving the rate of stillbirth, neonatal and maternal deaths by 2025 compared with 2010.
MPs on Monday published the first parliamentary report into birth trauma with “harrowing” evidence from more than 1,300 women about the “shockingly poor quality” of care they had received.
The cross-party inquiry heard how children had suffered life-changing injuries due to negligence, mothers had been left in blood-soaked sheets and covered in excrement, and hospitals had tried to cover up failures.
Felicity Benyon said she had a healthy bladder removed during an emergency caesarean section and was wrongly told that the placenta percreta had enveloped the bladder and that she would have lost it anyway.
She was only made aware after a urologist blew the whistle on the cover-up.
Another woman, Helen, told the report of her mental and physical pain a year after giving birth to her son, Julian, who was born with a hypoxic brain inquiry because of oxygen starvation during birth.
Another mother whose son had suffered brain damage at birth was accused “of inventing his injuries” as the hospital refused to take responsibility.
One woman was dismissed as being an “anxious mother” by staff before her baby died of the complications she had been concerned about.
The report said: “In many of these cases, the trauma was caused by mistakes and failures made before and during labour. Frequently, these errors were covered up by hospitals who frustrated parents’ efforts to find answers.”
Amanda Pritchard, the NHS chief executive, said the experiences of women outlined in the report were “simply not good enough”.
The inquiry was launched and chaired by Theo Clarke, the Conservative MP, after her own near-death experience while giving birth to daughter Arabella in 2022.
It comes after investigations into Shrewsbury and Telford Hospital NHS Trust, where failures had contributed to the deaths of 201 babies and nine mothers over 20 years, as well as scandals at Morecambe Bay and East Kent.
Donna Ockenden, the senior midwife who led the Shrewsbury inquiry and is now carrying out the largest maternity review in the UK at Nottingham University Hospitals NHS Trust, said she had given the Government a “clear blueprint and roadmap” for maternity services but “progress has been far too slow”.
‘Deflection and denial’
A report into East Kent by Dr Bill Kirkup published two years ago revealed a culture of “deflection and denial” among staff. “The effect of these behaviours was to cover up the truth,” he said.
The report found that good care was “the exception rather than the rule” as it made 12 recommendations, including an end to the “postcode lottery”, universal access to specialist mental health services, more midwives “to ensure safe levels of staffing”, mandatory trauma training, support for fathers, and digital health records for mothers.
The number of women who die during pregnancy or shortly after has risen to a 20-year high at 13.41 deaths per 100,000 pregnancies between 2020 and 2022, according to figures published by the MBRRACE-UK investigation into maternal deaths in the UK. The figure was 8.79 per 100,000 pregnancies between 2017 and 2019.
The NHS and the government have committed to a maternity services strategy in the wake of the report.
Victoria Atkins, the Health Secretary, said the findings were “harrowing”.
“I am determined to improve the quality and consistency of care for women throughout pregnancy, birth and the critical months that follow, and I fully support work to develop a comprehensive national strategy to improve our maternity services,” she said.
The NHS said it was working with leaders at all trusts with maternity and neonatal services in England on a national programme to create a culture where women are listened to and care is safe.
Ms Pritchard said: “We know there is more that can be done to prevent and improve support for birth trauma, which is why we are committed to working with the Department for Health and Social Care on a cross-government strategy to build on the NHS three-year delivery plan for maternity and neonatal services, so that we can continue to make care safer and more personalised for women and babies.”
