Actions needed following Each Baby Counts investigation

Actions needed following Each Baby Counts investigation

An investigation by the Royal College of Obstetricians and Gynaecologists has revealed the actions needed to prevent baby deaths and brain injuries during childbirth.

Published on 21st June, the Each Baby Counts study assessed 1,136 babies born in the UK in 2015 – 126 who were stillborn, 156 who died within the first seven days after birth and 854 babies who met the eligibility criteria for severe brain injury. The reviewers concluded that three quarters of these babies – 76% – might have had a different outcome with different care.

In many of the cases investigated, the factors leading to baby deaths and brain injuries included problems assessing fetal wellbeing during labour, and consistent issues with staff understanding complex situations, including interpreting fetal heartrate patterns.


The recommendations focus on a need for more teamwork in maternity units and include:

  • Formally assessing all low risk women on admission in labour to determine the most appropriate fetal monitoring method
  • Informing paediatric/neonatal teams of the pertinent risk factors in a timely and consistent manner
  • More support and management for staff to help them make complex clinical decisions, and understand their roles and responsibilities

Tragic consequences

Although the UK is still one of the safest places to give birth, the findings of this investigation underline the risk of negligence in maternity wards.

We have worked with many people whose lives have been changed forever as a result of negligent mistakes and have to live with the heartache of knowing that the outcome could have been different if extra measures or care had been put in place.

The findings of this report and recommendations should be taken on board by all maternity departments to ensure that there are the highest standards of care to reduce the risk of error, which can have tragic consequences for families.

Legal support and advice

If you have experienced any of the issues raised in the report, speak to our specialist clinical negligence team for further information on your legal rights and options.

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