Not every baby will survive, despite our best efforts, but it is utterly heartbreaking to see that in 3 out of 4 cases, different treatment would have lead to a better outcome for that child, and for that family.
There is no excuse for poor training and we need to do more to keep the number of maternal and neonatal deaths as low as possible.
The Each Baby Counts inquiry, by the Royal College of Obstetricians and Gynaecologists, looked at more than 700 recent neonatal deaths and injuries. It says three in every four of the babies may have had a different outcome had they received different care. The report looked at 1,136 stillbirths, neonatal deaths and brain injuries that occurred on UK maternity units during 2015. Local investigations into a quarter of the cases were not thorough enough to allow the report authors to do a full assessment of what might have gone wrong. In many of the 727 cases that could be reviewed in-depth, problems with accurate assessment of foetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting baby heart-rate patterns (on traces from CTG machines), were cited as significant factors.