The Scale of the Stillbirth and Neonatal Death Problem in the UK.
The number of stillbirths and neonatal deaths every year in the UK is more than twice the number of deaths on UK roads. While road safety attracts a huge amount of attention, resources and legislation, perinatal mortality still tends to be regarded as an unhappy fact of life about which little can be done.
But this is not true. Room for improvement is massive. If every health authority was able to perform like the best ones in the country do right now, UK perinatal mortality would be about two thirds of what it currently is. In other words, something like 30% of UK perinatal death is unnecessary. This might sound a bit wishful thinking, but a 30% reduction in perinatal death would only bring the UK into the same bracket as other, even marginally, well off European countries like Portugal and Greece. So, we are not talking about having to learn a lot of new things here, the knowledge of how to do it is already available in the UK, as the perinatal mortality rates of the better authorities clearly demonstrate.
And correcting the numbers for general health and relative deprivation (e.g. hospitals in relatively poor areas serve a population with more social health problems, and that increases mortality rates etc.) does little to change the picture. Of the 30% excess perinatal mortality seen in the UK, at least two thirds of it results directly from differences in medical and health care. This means that at least 20% of stillbirth and neonatal death is preventable by improving medical and health care in relatively failing areas, without having to do really difficult things like alleviate poverty in mothers. If there were access to the better care and better knowledge that is already available elsewhere in the UK, between 3 and 4 baby deaths would be saved every single day.
In an effort to reduce unnecessary deaths, the NHS runs something called “Clinical Governance”. The point of this process is to rigorously learn lessons from so called “sub-optimal care”. Theoretically, it puts structures and processes in place that help the NHS figure out and disseminate life-saving lessons. Because 20% of perinatal deaths are currently preventable by providing adequate care, and there are many Guidelines that describe what adequate care actually is, you might expect that NHS Clinical Governance would be awash with investigations into the perinatal deaths that do occur.
Unfortunately not. The data suggests that currently only about 1 in 8 of the 20% excess, preventable, sub-optimal baby deaths are investigated at all. So, 7 out of every 8 preventable baby deaths are going uninvestigated and unlearned from. Given the NPSA’s estimate of 95% of unreported preventable death generally in the UK, a large proportion of these unlearned from deaths are probably not being reported as preventable anywhere in the system. In CEMACH (Confidential Enquiry into Maternal And Child Health) reports, for example, the lion’s share of causes of stillbirth and neonatal death is still “unexplained” and the implication is that this is because most cases, even the more serious ones, are not investigated. This leaves the NHS, and organisations like CEMACH, SANDS and BLISS, having to guess at the scale of, the reasons for and the solutions to this by definition solvable problem.
Meanwhile, according to surveys like the King’s Fund Enquiry, NHS staff themselves complain that they fill in endless incident forms and do not see any actions or changes as a result. They complain that they see the same incidents occurring over and over again, and that the only hope of breaking the cycle is complaints, litigation or where there is some kind of scandal that hits the papers.
So, it is not only medical and health care that are failing to save babies in the UK. It would seem that Clinical Governance, at least for perinatal death at the moment, is also failing, even where the lessons have already been learned by some.
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