We investigate incidents that meet the Each Baby Counts criteria or our defined criteria for maternal deaths.
Each Baby Counts is the Royal College of Obstetricians & Gynaecologists’ national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour.
During our investigations we look into all clinical and medical aspects of the incident, as well as aspects of the workplace environment and culture surrounding the incident.
Eligible babies include all term babies (at least 37+0 completed weeks of gestation) born following labour, who have one of the below outcomes.
Where the baby was thought to be alive at the start of labour but was born with no signs of life.
Early neonatal death
When the baby died within the first week of life (0-6 days) of any cause.
Severe brain injury
Severe brain injury diagnosed in the first seven days of life, when the baby:
- Was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE).
- Was therapeutically cooled (active cooling only).
- Had decreased central tone and was comatose and had seizures of any kind.
We don’t investigate babies whose outcome was the result of congenital anomalies.
Definition of labour
The definition of labour that applies to the Each Baby Counts programme includes:
- Any labour diagnosed by a health professional, including the latent phase of labour at less than 4 cm cervical dilatation.
- When the woman called the unit to report any concerns of being in labour, for example (but not limited to) abdominal pains, contractions or suspected ruptured membranes.
- Induction of labour.
- When the baby was thought to be alive following suspected or confirmed pre-labour rupture of membranes.
This means that for us to conduct an investigation of a maternity incident under the subsequent Each Baby Counts criteria, the mother must have been in term labour as defined by these conditions.
We investigate direct or indirect maternal deaths of women while pregnant or within 42 days of the end of pregnancy.
Direct deaths include those resulting from obstetric complications of the pregnant state (pregnancy, labour and postpartum), from interventions, omissions incorrect treatment or from a chain of events resulting from any of the above.
Indirect deaths include those from previous existing disease or disease that developed during pregnancy and which was not the result of direct obstetric causes, but which was aggravated by the physiological effects of pregnancy in the perinatal period (during or within 42 days of the end of pregnancy).
We don’t investigate coincidental maternal deaths or suicides.
What we can’t investigate
Some maternity incidents that meet the Each Baby Counts criteria will have occurred just prior to the national commencement of our investigation programme, or within a period where the programme had commenced nationally but, due to the phased rollout process, had not yet been implemented in the trust where the incident took place.
There will also be some incidents with characteristics which fall close to, but not completely within, the scope of an Each Baby Counts criterion.
Due to very specific conditions set out in the directions that govern our programme, we have no remit to investigate these incidents and the responsibility to complete the investigation remains with the local trust.
We recognise that this may be disappointing for mothers and families who hope to see lessons from their personal experience contribute to changes at a national level to improve maternity safety.
As part of our programme we continuously assess the effectiveness of the Each Baby Counts criteria, which governs our scope of incidents for investigation. There are no current plans to change the criteria, but we hope that future adaptations will introduce some flexibility to how we can apply the criteria.
Family consent is of fundamental importance to our investigations. Even if an incident falls within the Each Baby Counts criteria, if the family doesn't give their permission then we don’t have remit to investigate the incident. In such cases, responsibility for conducting the investigation returns to the trust.
Families can change or reconsider their initial decision at a later date, but to ensure the opportunity for learning isn’t lost for the trust and staff, we ask families to have made a firm decision, provided in writing, within four weeks.
If a family comes back to us after this, we liaise with the trust on how to take this forward, but any delay to commencing an investigation or handover from trust to HSIB (or vice versa) presents complications for the process, and risks reducing the quality of the investigation evidence.