If current guidelines on standards of care were actually delivered in practice, over 500 babies a year could go home in their parents arms, rather than in a coffin.

Too many babies are dying because doctors and midwives are not doing their jobs properly. The findings of the stillbirth confidential inquiry in 2015 were appalling.

The review looked at full term, normally formed babies who tragically died before labour. If they had been delivered in the days prior to death there would be every chance of the survival of a healthy infant and negligible risk associated with induction of labour for the woman. Astonishingly, it found that :

of deaths had failures in care that could have changed the outcome

  • Connector.

    Monitoring Growth

    There was evidence of a failure to monitor fetal growth in line with NICE guidance, either by not taking symphysis fundal height measurements, not plotting the measurements on a chart or not responding when growth was abnormal

  • Connector.

    Fetal movements

    There was evidence of a failure to respond appropriately to attendance and repeat attendance by women with reduced fetal movements; either a lack of investigation, misinterpretation of the fetal heart trace or a failure to respond appropriately to additional risk factors.

  • Connector.


    There was evidence of a failure to identify risk factors for gestational diabetes and to refer women for testing as per the NICE Guideline on Diabetes in Pregnancy.

Unforgivingly, nothing has changed in 15 years

An extensive review of antenatal and postnatal care of over 400 cases by CESDI in 1996–97 found that 45% of stillbirths were associated with suboptimal care. So standards may have actually got worse since then.

Even the issues remained the same:

  • Changes in babies activity, failure to act on suspicious antenatal CTG
  • Identification of growth restriction and action on diagnosed growth restriction
  • Poor diabetic management, failure to do or repeat glucose tolerance test (GTT)
  • Other failures to assess and react to risks

Had the 1997 report been
acted upon, over

babies could have been
saved up to 2015

(And that’s a conservative estimate)

The NHS wastes billions due to negligence in maternity care

Maternity is by far the biggest cause of compensation claims for the NHS, responsible for over 40% of claims by value. If just a tiny fraction of this was invested on preventing stilbirths, so many lives could be saved, along with billions of pounds.

It paid
in compensation in 2014/15
And set aside
for future compensation
A low risk primigravid woman reported an absence of fetal movements at 39+1 weeks gestation when she attended the community midwifery unit. CTG monitoring, appeared to be within normal limits and she was reassured that all was well. She attended at 40+1 weeks gestation for a membrane sweep and reported a reduction in her baby’s movements and spontaneous rupture of membrane. She was discharged home without a CTG or further investigation. She attended again at 41+0 weeks gestation with irregular contractions. She was prescribed analgesia and discharged home. At 41+5 weeks she attended with irregular contractions and on admission, intrauterine death was confirmed by ultrasound scan.Example from MBRRACE confidential enquiry, Nov 2015

What work is currently underway?


A national collaboration investigating maternal deaths and severe morbidity, stillbirths and infant deaths and morbidity.


Works to improve NHS Maternity Services in order to reduce the avoidable deaths and injuries of babies and mothers during labour.


RCOG’s quality improvement programme. Aims is to reduce avoidable harm in labour in the UK by 50% by 2020.