Investigating perinatal deaths, a new approach?

The medical negligence team at Hodge Jones & Allen is frequently contacted by relatives of patients who have died who find their grief compounded by a lack of transparency in obtaining information about exactly what happened. Whilst the death of any loved one can be hard to understand or bear, the death of a baby, either before or around the time of birth, is a devastating event.

The account given on this morning’s Today programme by a bereaved parent was compelling to listen to, and sadly recognisable by those of us who work in clinical negligence. Whilst the full details were not given it is clear that both internal and external investigations fell far short of their legitimate expectations particularly when the investigations failed to take the parents’ reported experience of the birth into account.

This is not uncommon, so Jeremy Hunt’s announcement expected later today that every parent who finds them self in this position (including those whose babies are profoundly brain damaged at birth) will be entitled to an independent investigation is welcome. He is also to announce that the government will look into expanding the remit of Coroners to look at still births. Moreover, from April 2018 all stillbirths, early neonatal deaths and severe brain injury cases will be referred to the newly established Health Care Safety Investigation Branch.

These are all steps in the right direction and if properly resourced and implemented could lead to a significant improvement in assisting bereaved parents to understand what happened and cope with their loss.

This announcement coincides with the publication today of the MBRRACE-UK Perinatal Confidential Enquiry, whose foreword notes that deficiencies in care are a factor in many perinatal deaths:

… the death of any woman or baby during pregnancy is a tragedy, and this latest report from the national perinatal mortality enquiry highlights that there is still much more to be done. Despite the fall in mortality rate, these deaths remain a major cause for concern, particularly as the vast majority of the women were receiving direct maternity care when their baby died or when the event in labour or delivery occurred which led to this tragic outcome. For nearly 80%, it was identified that different care might have made a difference, echoing the findings of the Each Baby Counts programme.