The NHS doesn’t even consider the death of a healthy, full term baby to be a serious incident. No lessons are learned, and the truth is buried along with the child.
Not taken seriously
Stillbirths are not investigated systematically and robustly. The death of a healthy, full term baby immediately prior to birth is excluded from being a serious incident under the NHS framework. This means no investigation or root cause analysis.
Lack of independence
Complaints are seen as a financial and reputational risk, rather than an opportunity to learn lessons and save lives in future. Hospitals investigate their own complaints, with no regard for conflicts of interest.
There is a strong culture of defensiveness and closing ranks when mistakes occur. This is unwarranted – most parents do not want financial compensation or to blame someone – nothing will bring their child back. Parents just don’t want it to happen to anyone else.
Lessons need to be learned
There is no mechanism by which findings that could save lives elsewhere are shared. Investigations focus narrowly on the lowest applicable standards (e.g. whether NICE or a local policy was followed) – rather than whether the Trust could learn from other sources (e.g. national guidance).
The misapprehension that all stillbirths are unavoidable tragedies results in bereaved parents being patronised and treated as if it is ‘just the grief speaking’, when often fatal errors in care were made.
Term stillbirth Confidential Inquiry findings
The guidelines and recommendations that do exist are frequently ignored.
“All stillbirths should be reviewed in a multiprofessional meeting using a standardised approach to analysis for substandard care and means of future prevention. Results of the discussion should be recorded in the mother’s case record and discussed with the parents.”RCOG Green Top 55: Late Intrauterine Fetal Death and Stillbirth
“Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there is a strong case to include a requirement that investigation of these incidents be subject to a standardised process, which includes input from and feedback to families, and independent, multidisciplinary peer review, and should certainly be framed to exclude conflicts of interest between staff.” The Report of the Morecambe Bay Investigation, recommendation 23