Review of Perinatal & Infant Deaths and Maternity Care in Walsall

Report to Walsall Borough Council

26 November 2015

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Foreword

This report was commissioned by Walsall Borough Council to investigate the underlying causes of high perinatal mortality in the Walsall population.

There were 66 deaths between April 2010 and March 2014 which fit the inclusion criteria, including 42 stillbirths, 16 neonatal deaths and 8 sudden infant deaths. Each case underwent in‐ depth analysis of standards of care and avoidability of outcome, using the SCOR (standardised clinical outcome review) software and examination by external panel.

Panels identified examples of good practice as well as substandard care. Most cases with substandard care related to the earlier years of the 4 year period investigated, with evidence that processes had been put in place in recent years and had led to improvements.

Specific learning points from the cases examined included the need for

appropriate risk assessment and a thorough review of fetal growth surveillance protocols and

techniques, including standardised fundal height measurements and serial scanning;

a thorough review of neonatal care, and implementation of Newborn Network guidance for

tertiary referral;

establishment of a self‐sustaining process of unit based standardised reviews of perinatal

deaths, to improve ongoing learning from adverse outcomes.

The report details the main findings from the reviews of antenatal, neonatal and infant deaths, specific learning points (Section 11) and a Summary with Recommendations (Section 12).

The findings and conclusions have been fed back, discussed and welcomed by stake holders, consisting of lead clinicians including clinical director and head of midwifery, the Clinical Network, Clinical Commissioning Group, Public Health and Walsall Borough Council.

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Glossary of Terms / Abbreviations

Term or Abbreviation

Definition

ANNP Advanced Neonatal Nurse Practitioner

BMI Body Mass Index

CDOP Child Death Overview Panel

CESDI Confidential Enquiry into Stillbirths and Deaths in Infancy

CMW Community Midwife

CTG Cardiotocography – electronic fetal monitoring

DFM Diminished fetal movements

EDD Estimated Date of Delivery – usually based on dating ultrasound scan, or last menstrual period if scan not done

FGR Fetal Growth Restriction

FH Fetal Heart; FHR – Fetal heart rate

G (Gravida) Number of Pregnancies

GROW Gestation Related Optimal Weight – principle used to generate customised growth charts or weight centiles

GTT Glucose tolerance test – blood test performed to diagnose gestational diabetes

HDU High Dependency Unit

HR Heart Rate

LNU Local Neonatal Unit (Level 2)

LSCS Lower Segment Caesarean section

MLC Midwifery led care – maternity care provided by a midwife or midwifery team only

MLU Midwifery Led Unit – a dedicated unit to deliver maternity care by midwives only, including birth

NICU Neonatal Intensive Care Unit (Level 3)

NLS Neonatal Life Support

P (Parity) Number of previous infants a woman has delivered live born or stillborn after 24 weeks gestation

Partogram A graphic representation of the progress of labour

P/H Past History

PI Perinatal Institute

RCOG Royal College of Obstetricians and Gynaecologists

RWH Royal Wolverhampton Hospital

SANDS Stillbirth and Neonatal Death Society

SCBU Special Care Baby Unit (Level 1)

SFH Symphysis fundal height

SGA Small for Gestational Age

SIDS Sudden Infant Death Syndrome

SpR Specialist Registrar

SUDI Sudden Unexplained Death in Infancy

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1. CONTENTS, AUTHORS & ACKNOWLEDGEMENTS

Chapter Page

Foreword 3

Glossary of Terms 4

1 Contents and Acknowledgements 5

2 Introduction: Perinatal and Infant Mortality 6

3 Maternity and Neonatal Care in Walsall 7

4 Aims of the Review 7

5 Methodology 8

6 Stillbirths 11

7 Neonatal Deaths 17

8 Sudden unexplained deaths in infancy 22

9 Overarching Themes 23

10 Trust based reviews 23

11 Learning Points 25

12 Summary and Recommendations 27

13 Stakeholder Responses 29

Authors

Lorraine Ecclestone RGN, RM, BA (Hons) PGDip Project Manager; Midwife Specialist, Perinatal Institute Sally Giddings RGN, RM, DMS, BSc (Hons), SoM Head of Midwifery, Perinatal Institute Professor Jason Gardosi MD FRCSED FRCOG Director, Perinatal Institute (senior author of the report)

Acknowledgements

We would like to thank Carol Hollington Quality and Risk Matron, Walsall Healthcare NHS Trust ‐ for identifying notes, protocols and associated material Dr Adam Gornall Consultant in Feto‐maternal Medicine and CD for Maternity; Lead Obstetrician,

Staffordshire, Shropshire & Black Country Newborn & Maternity Network; and Dr Sanjeev Deshpande Consultant Neonatologist, Shrewsbury and Telford Hospitals ‐ for acting as external advisors and panel members for the reviews

Steering Group

Dr Uma Viswanathan Consultant in Public Health, Walsall Borough Council (Chair) Esther Higdon Senior Programme and Commissioning Manager, Walsall Public Health Diane Osborne Walsall Clinical Commissioning Group Karen Palmer Head of Midwifery, Walsall Healthcare NHS Trust Dr John Pepper Clinical Director, Obstetrics – Walsall Healthcare NHS Trust (to Jan 2015) Dr Arundhati Mulay Clinical Director, Obstetrics – Walsall Healthcare NHS Trust (from Feb 2015) Dr Bashir Mohammed Consultant Paediatrician – Walsall Healthcare NHS Trust

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2. INTRODUCTION: PERINATAL AND INFANT MORTALITY IN WALSALL

This report presents the findings and conclusions of an independent case review of perinatal and infant deaths in Walsall, 2010‐2014. The review focuses on the standard of care received by the mothers and babies affected, and seeks to understand the causes and underlying factors associated with the outcomes.

Perinatal and infant mortality in Walsall is higher than the regional and national average. This is illustrated in Figures 1 & 2. (Source: ONS)

Contributing factors included smoking in pregnancy, consanguinity, maternal obesity and social deprivation. Infant mortality rates were 6 fold higher in the most deprived compared to the least deprived areas. There was also wide variation in low birthweight rates between wards. Key priorities in the infant Mortality Action Plan included social determinants, antenatal care and intrauterine growth restriction [1].

Walsall Borough Council commissioned this enquiry to investigate the underlying causes of high perinatal and infant mortality in its population, to help inform clinicians, public health as well as commissioners of maternity services. Following a competitive tender, the project was awarded to the Perinatal Institute in 2014, to be undertaken within a 12 month timeframe.

1. Walsall Joint Strategic Needs Assessment Refresh 2013 http://cms.walsall.gov.uk/walsall_jsna_refresh_draft_10.pdf

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3. MATERNITY AND NEONATAL CARE IN WALSALL

Maternity care in Walsall is provided by Walsall Healthcare NHS Trust. Within the Trust there is a consultant led obstetric unit and a freestanding midwifery led unit, (MLU). The MLU is located within a mile of the Obstetric unit, requiring ambulance transfer should the need arise.

According to the West Midlands Local Supervising Authority (LSA), Walsall’s delivery rate in 2013‐2014 was 4672 with 138 whole time equivalent midwives, giving a ratio of birth to WTE midwives of 34:1. There were 10 Supervisors of Midwives, giving Walsall a ratio of 21 midwives per supervisor (average for the West Midlands LSA: 15). The vaginal delivery rate at Walsall for 2013‐14 was 59%, caesarean section rate 28%, and instrumental delivery rate of 13%, each within range of the Black Country Area.

The Local Neonatal Unit (LNU) has 2 intensive care unit cots, 2 high dependency unit cots and 11 special care cots. The nearest, network linked Neonatal Intensive Care Unit (NICU) is at the Royal Wolverhampton NHS Trust.

4. AIMS OF THE REVIEW

A steering group was set up, chaired by Walsall Council, with representatives from the Council, Manor Hospital, the Clinical Commissioning Group and the Perinatal Institute. As a preparatory phase, Walsall public health undertook a review of the demographics and mortality rates with regional and national comparisons, highlighting some of the challenges in the Walsall population.

Based on this, and in consultation with the steering group, selection criteria were agreed which were to be applied to ALL deaths that had occurred from April 2010 to March 2014. With assistance from the risk manager at the Trust, basic information including short summary vignettes were obtained.

On preliminary examination of this cohort, and based on previous experience with regional case reviews, the Perinatal Institute proposed, and the steering group agreed, that all eligible cases be examined, including each part of the perinatal continuum i.e. antenatal, intrapartum and neonatal period. In addition, sudden unexplained deaths in infancy up to 1 year would also be reviewed.

The aim of the project was to

Examine the cohort of cases with adverse outcome and distil causes and contributing factors Identify areas of good practice Identify aspects in the provision of maternity and neonatal care which require improvement Make recommendations on how these issues can be addressed Prepare a report for publication and presentation to stakeholders

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5. METHODOLOGY

5.1 Identification of cases In order to ensure that the cases reviewed were a true representation of the deaths in Walsall the following criteria were applied:

All deaths were to women resident in Walsall at the time of booking for maternity care

Maternity and neonatal care took place at Walsall Healthcare NHS Trust Neonatal and infant deaths occurred / were certified at Walsall Healthcare NHS Trust

Gestation at delivery was from 24 weeks Neonatal and infant deaths occurred up to 12 months of age

Deaths attributed to congenital anomalies were excluded

Deaths occurred between 1st April 2010 and 31st March 2014

A database of all deaths was received from Walsall Healthcare NHS Trust, (222 cases). After removing the cases that did not meet the criteria, 66 cases were left for review, as detailed in Table 5.1.

Table 5. 1 ALL DEATHS 2010‐2014 (stillbirths, neonatal deaths and SUDIs)

222

CASES EXCLUDED

Non Walsall residents

46

Death occurred outside Walsall

22

Congenital anomalies

31

Extreme prematurity <24 weeks gestation 38

Deaths after age 28 days (excluding Walsall SUDI’s)

19

TOTAL EXCLUDED

156

CASES MEETING INCLUSION CRITERIA

Antenatal/intrapartum related stillbirths

42

Early Neonatal Deaths (<7 days)

13

Late Neonatal Deaths (7‐28 days)

3

Sudden Unexplained Deaths in Infancy (SUDI, to 12 months)

8

TOTAL INCLUDED IN REVIEW

66

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The distribution of the cases by year of delivery is given in Table 5.2.

Table 5.2 Year of delivery of cases in the review 2010/11 2011/12 2012/13 2013/14 Total (66)

Stillbirths 11 11 9 11 42

Neonatal Deaths 3 2 6 5 16

SUDI 4 2 1 1 8

The case notes, including all printouts from electronic records where available, were released to the Perinatal Institute for review, with the agreement of the Caldicott Guardian (Medical Director) of Walsall Healthcare NHS Trust. All relevant Trust policies, procedures and guidelines applicable to the cases were also released for review.

Descriptive analysis was conducted on socio‐demographic and clinical factors, health behaviours and ‘avoidable factors’. These are summarised later in the report and provide insight into the population characteristics of the mother and infants, and of the maternity care received, the cause of death and an assessment of the ‘avoidable factors’ identified. This is followed by a more detailed analysis of comments by the panels including recommendations and learning points.

5.2 SCOR (Standardised Clinical Outcome Review)

Each set of case notes was entered onto the SCOR software application, which helps the structured recording and assessment of care provided in each phase of pregnancy, and produces a taxonomy of care issues and substandard care factors and case summary to facilitate independent panel review.

Fig 3. Example of an input screen used in SCOR

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5.3 Panel Review Each case was reviewed by an independent expert panel. The panels consisted of senior clinicians external to Walsall and were chaired by the Director of the Perinatal Institute. In addition to providing a structured approach for the review using SCOR, this method assisted in achieving consistency in the evaluation of the care provided. The overall significance of any avoidable factor was assessed and graded using the standard CESDI (Confidential Enquiries into Stillbirths and Deaths in Infancy) criteria. (Table 5.3)

Table 5.3: Grading of level of care

Grading

Level of Care

Grade 0

No suboptimal / substandard care

Grade 1 Suboptimal care, but different management would have made no difference to the outcome

Grade 2 Suboptimal care; different care might have made a difference (possibly avoidable death)

Grade 3 Suboptimal care; different care would reasonably be expected to have made a difference (probably avoidable death)

Conclusions concerning the standard of care and avoidability of outcome were agreed by consensus, and the grading section of SCOR was completed as an accurate record. (Fig 4)

Fig 4 – Example of SCOR entry of grading of care and reasons given by the panel

Each panel session reviewed between ten and twelve cases, examining professional healthcare/clinical issues and all aspects of the antepartum, social, intrapartum, postpartum and neonatal care. Areas of good practice were also highlighted.

Clinical information plus any post mortem and placental histology reports were used to classify the primary cause or associated factor / condition relevant to the death.

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6. STILLBIRTHS

42 cases met the inclusion criteria and all were reviewed.

6.1 Characteristics of the 42 stillbirths are shown in Table 6.1 A:

Maternal and Pregnancy characteristics

Stillbirths (N=42)

n %

Maternal Age <20 10 24

35+ 5 12

Parity P0 19 45

P4+ 4 9.5

Ethnic Origin

British European 25 60

Eastern European 3 7

Indian 3 7

Pakistani 6 14

Bangladeshi 4 10

African ‐Caribbean 1 2

Chinese 0 0

BMI

<20 5 12

20‐25 16 38

26‐29 8 19

30‐35 5 12

35+ 8 19

Smoking

Yes

9

21

Consanguinity

Yes

5

12

Gestational age

<29 12 29

29‐33 12 29

34‐36 9 21

37+ 9 21

Birthweight SGA 23 55

LGA 1

Post mortem done 15 36

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Table 6.1B: PAST HISTORY Stillbirths

N=42

n % Obstetric history Previous pregnancy problem (multiple miscarriage, preterm birth, placental abruption, pre-eclampsia)

6

14

Previous SGA baby 5 12 Previous stillbirth 1 2 Previous Caesarean section 11 26 Other 0 None 26 62

Medical history Significant pre‐existing medical conditions, e.g. hypertension, diabetes

12

28

Significant family history, e.g. diabetes 15 36 Significant previous mental health issues e.g. depression

5

12

None 27 64

Table 6.1B shows the past obstetric and medical history of the pregnancies which ended in stillbirth. The majority of cases had no obstetric (62%) or medical (64%) history

Table 6.1C: CARE IN CURRENT PREGNANCY Stillbirths

N=42

n % Timing of booking visit < 12+6 weeks gestation 35 83 13+0 – 20+6 weeks gestation 5 12 21+0 weeks gestation or more 2 5

Unbooked 0 0

Intended type of care at booking Obstetric‐led 34 81

Midwifery‐led 8 19

Mode of delivery Vaginal cephalic 31 74 Vaginal breech 6 14

Caesarean Section Emergency 3 7 Elective 2 5

Table 6.1C shows that most of these pregnancies were booked early. The majority (81%) were considered to require obstetric led care.

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6.2 Cause of death

15 of the 42 stillbirths (36%) had a post‐mortem.

Table 6.2 illustrates the cause of death for stillbirths following panel review. The most common causes were fetal growth restriction (57%) followed by maternal disorders (12%), infection (10%) and placental abruption (10%). Four deaths remained unexplained.

Table 6.2. CAUSE OF DEATH ‐ STILLBIRTHS (N=42)

n

%

Fetal growth restriction * 24 57

Hypertension or other maternal disorders 5 12 Abruption 4 10

Infection 4 10

Umbilical cord accident 1 2

Unexplained 4 10 * defined as SGA (GROW <10

th centile) or placental insufficiency

6.3 Themes from the Panel Reviews

6.3.1 Good Practice ‐ Panels highlighted areas of good practice which included:

Pre‐conceptual care: several instances where GPs had followed guidance from a previous

postnatal consultant plan, which led to the appropriate care • Good continuity of care by community midwives • Safeguarding referrals – pathway and documentation concerning safeguarding tended to be

thorough and concise • Delivery of stillbirth –care of women during labour after an intrauterine death was generally good • Use of SBAR (Situation, Background, Assessment, Recommendation) communication. This was

identified as an area of good practice and records of this being used were evident in the maternity notes

6.3.2 Risk assessment at booking.

In a number of pregnancies there was failure to recognise risk factors, for example obesity, late booking and multiple fibroids, all requiring consultant referral and serial scans. Social risk assessment was inconsistent with some women being appropriately referred but others not receiving referral for smoking, mental health, and / or healthy weight management.

Many cases demonstrated that the consequence of a suboptimal risk assessment at booking resulted in an incorrect care pathway which, unless there was a change of midwife or an additional risk identified, continued for the duration of her pregnancy.

Suboptimal risk assessment was illustrated in cases where women who booked late were cared for on a low risk pathway. This was a deviation from local Trust guidelines whereby these women should have been referred for consultant‐led care.

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6.3.3 Decreased Fetal Movements (DFM).

34 of the 42 stillbirths (81%) had at least one episode of decreased fetal movements prior to demise. An issue highlighted by the panels was that some women waited up to 11 days before presenting with DFM, and in many cases there was no documented evidence of fetal movements having been discussed antenatally. The chart below details the attendances with decreased fetal movements and the length of time women waited to present with them.

Table 6.3 Mothers with at least 1 episode of DFM n=34 %

First DFM to time of presentation < 12 hrs 9 26

12‐24hrs 8 24

over 24hrs 17 50

In 14 of the 34 DFM cases (41%) there was NO evidence in the notes of advice regarding DFM having been given antenatally. In the 17 cases where the delay to presentation was > 24 hours, 10 (59%) of mothers did not have a record of fetal movements having been discussed antenatally.

6.3.4 Recognition/Management of Fetal Growth Restriction (FGR).

Failure to recognise fetal growth restriction was the most common theme. 24 (57%) of the stillbirths were growth restricted (<10th customised centile, or placental insufficiency) and in 14 of these cases (61%), fetal growth restriction was not recognised antenatally.

Four of the deaths occurred at very early gestations (24‐25 weeks). A closer examination of the remaining 20 stillbirths with FGR is shown in Table 6.4

Table 6.4 ‐ Details of fetal growth surveillance n %

No antenatal risk factor; died at 27 weeks 1 5.0

Suspicion of FGR based on fundal eight measurement but no referral made for further investigation

5

25.0

Early pregnancy risk of FGR recognised and 28/34 week scans instituted according to local protocol, but death occurred at other times in gestation

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55.0

SGA / FGR diagnosed on scan but delay in management 3 15.0

Total 20 100.0

This analysis showed that in a quarter of cases, there was an indication to refer on the basis of plotted fundal height measurements, but this was not done.

The majority of these deaths (55%) were cases of missed FGR in pregnancies which had indications for serial assessment of fetal growth by ultrasound ‐ e.g. past history, raised BMI, fibroids. The panel reviews found that the local serial scanning policy (28 and 34 weeks) failed to identify the growth failure in these pregnancies.

6.3.5 Documentation.

Issues with documentation were observed in the majority of cases reviewed, and included all grades and disciplines of staff involved in the care. It related to poor documentation or failure to document at all.

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Often notes were not written contemporaneously, requiring them to be written retrospectively. While the hand held pregnancy records were usually completed thoroughly at booking, there were often inconsistencies in documentation exacerbated by combined written and electronic records, especially when trying to review management plans.

In some cases midwifery documentation was limited, especially during admissions to the fetal and maternal assessment unit, often with maternal and fetal observations omitted. Documentation was also limited in some cases at time of diagnosis of intrauterine death including counselling and plan of care. Records often had missing or illegible dates, times, signatures, printed surnames or grades. The panels commented that partograms were rarely completed for women in labour with an intrauterine death, despite the importance of continued monitoring of the woman and her progress.

Discrepancies were also noted at the time of delivery, with neonatal resuscitation records varying significantly, dependent upon who was completing them. For example, two resuscitation records were completed for the same case by two different practitioners, and had different observations including colour, respiratory effort, tone and hence Apgar scores.

Recurrent inconsistencies were noted by the panel with drug prescription cards. Syntometrine was very rarely recorded on the drug prescription chart when administered by a midwife at delivery. Pre‐printed prescription charts for termination of pregnancy/intra uterine death under 24 weeks gestation were often used for intrauterine deaths over 24 weeks and there were discrepancies noted between drugs signed for on prescription charts and details of their administration in the midwifery records.

6.3.6 Clinical Leadership

There were instances of failure to consult more experienced professionals, or inappropriate grades of staff involved in care. Panels were concerned that Foundation Year doctors were seeing high risk women with complex histories in antenatal clinics without direct supervision of senior grades. Cases of high risk women presenting in triage with complications, for example threatened preterm labour or symptoms of pre‐ eclampsia, and were not always discussed with consultants to ensure management plans were appropriate. In some cases it was felt that women were discharged prematurely.

6.3.7 Communication Good practice was noted in communication with the use of SBAR (Situation, Background, Assessment, and Recommendation) which provided a clear, structured approach to clinical situations. This was especially apparent on the delivery suite.

However some issues were identified in communication between health professionals and women including

‐ Poor information giving to women e.g. fetal movements in pregnancy ‐ Lack of referral to specialists e.g. smoking cessation, mental health team ‐ Inadequate professional translation service evident for some non‐English speaking women

6.3.8 Education, Knowledge and Training. There was often an apparent lack of knowledge around the use of fundal height measurements, the use of customised growth charts and the appropriate interpretation and management of women suspected of fetal growth restriction. In many of these cases the lack of knowledge was attributed to the outcome.

In all diabetes cases reviewed there were elements of substandard care including delay in being seen by specialist teams, poor medication management and lack of clear management plans. Care often appeared disjointed, being usually led by a diabetes specialist nurse in conjunction with various obstetricians rather than a dedicated diabetes team. In the case of pre‐gestational diabetes, the diabetes guideline (e.g. aspirin from booking) was not followed.

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Grade 2010/11 2011/12 2012/13 2013/14

0 3 8 4 3

1 0 2 1 3

2 5 2 4 0

3 4 2 1 0

6.4 Grading

All grades were assigned by consensus.

Table 6.5 summarises the substandard care grades for stillbirths

Grade

Level of care

Stillbirths

0

No suboptimal / substandard care

18

1 Suboptimal care, but different management would have made no difference to the outcome

6

2 Suboptimal care; different care might have made a difference (possibly avoidable death)

11

3

Suboptimal care; different care would reasonably be expected to have made a difference (probably avoidable death)

7

Total

42

Of the 42 stillbirth cases reviewed, the panel found substandard care in 24 (57%) of cases, which in 18 (43% of total) was possibly or likely to be associated with the outcome.

An analysis of Grading by year is shown in Table 6.6. There appeared to be a reduction of potentially avoidable deaths (Grades 2 and 3) over time, with half the deaths (9) in 2010/11, and none recorded in 2013/14.

Table 6.6

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7. Neonatal Deaths

16 neonatal deaths met the inclusion criteria and all cases were reviewed. The characteristics of the cases are detailed below. In similarity to the stillbirth cases the majority (68%) were to White British women. 5 women smoked, and 8 (50%) had a raised BMI. 8 neonates (50%) were SGA at birth.

All the neonatal deaths were preterm deliveries with the exception of one, which was a term delivery resulting in a sudden unexplained death at home.

7.1 A: Characteristics of the 16 neonatal deaths are shown in Table 7.1A

Table 7.1.A Maternal and Pregnancy characteristics

Neonatal deaths (N=16)

n %

Maternal Age <20 1 6

>35 5 31

Parity P0 4 25

>P4 0 0

Ethnic Origin

White British 11 68

Eastern European 1 6

Indian 1 6

Pakistani 1 6

Bangladeshi 1 6

Chinese 1 6

BMI

<20 2 12

20‐25 6 38

26‐29 5 32

30‐35 1 6

>35 2 12

Smoking

Yes

5

32

Consanguinity

Yes

0

Gestational age

<29 8 50

29‐33 6 38

34‐36 1 6

37+ 1 6

Age at Death

<1hour 5 31

1 hour‐24 hours 4 25

24 hours – 7 days 4 25

7 days – 28 days 3 19

Birthweight SGA (<10th cust centile) 8 50

LGA (>90th cust. Centile) 0

Post mortem done Yes 5 31

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Table 7.1B shows the past history obstetric and medical history of the pregnancies which ended in neonatal deaths. The majority of cases had no significant obstetric or medical history

TABLE 7.1B: PAST HISTORY Neonatal deaths

N=16

n % Obstetric Previous pregnancy problem (multiple miscarriage, preterm birth, placental abruption, pre-eclampsia)

3

19

Previous FGR baby 6 37.5 Previous stillbirth 0 0 Previous Caesarean section 2 12.5 None 10 62.5

Medical Significant pre‐existing conditions e.g. hypertension, diabetes

4 25.0

Significant family history, e.g. diabetes 3 19 Significant previous mental health issues e.g. depression

1 6

Table 7.1.C: Care provided during current pregnancy

Table 7.1.C: CARE IN CURRENT PREGNANCY

Neonatal deaths N=16

Timing of booking visit n % < 12+6 weeks gestation 12 75 13+0 – 20+6 weeks gestation 3 19 21+0 weeks gestation or more 0 0

Unbooked 1 6

Intended type of care at booking Consultant‐led care 16 100 Midwifery‐led care 0 0

Intended type of care at onset of labour Consultant‐led 16 100 Midwifery‐led 0 0

Mode of delivery Spontaneous vaginal 7 44 Breech 0 0 Caesarean Section

Emergency 9 56

Elective 0 0

All women whose pregnancy resulted in a neonatal death were considered high risk at booking and were cared for by a consultant obstetrician. 9 (56%) cases were delivered by emergency caesarean section.

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7.2 Primary cause of neonatal deaths as defined by panel review

5 of the 16 neonatal of deaths (31%) had a postmortem

Table 7.2 illustrates the cause of death for the neonatal deaths following panel review. The most common causes were respiratory (31%) and neurological disorders (25%); two neonates had cardiac anomalies detected only at post‐mortem; and one of the deaths was a SUDI at 3 days.

Table 7.2. Cause of Neonatal Death

n (total N=16)

%

Respiratory Disorder 5 31 Neurological disorder 5 31

Infection 3 19 Cardiac anomaly 2 13 Sudden unexpected death 1 6

7.3. Panel Review Themes

7.3.1. Good practice

The panels identified several areas of good practice including:

Community midwives’ risk assessment including women transferring care to Walsall; the community midwives appropriately risk assessed all the women antenatally whose pregnancies resulted in a neonatal death. They also appropriately identified and managed a woman at high risk of fetal growth restriction which was not identified at a neighbouring Trust

Care of the neonates by ANNP / nursing team was generally of good quality ANNP documentation was good. The documented reviews and management plans by the ANNP

tended to be thorough and appropriate Initial resuscitation tended to follow Newborn Life Support (NLS) guidance No issues were identified with the multidisciplinary approach to resuscitation in A&E

7.3.2 Substandard obstetric issues in cases resulting in neonatal deaths

Cardiotocograph (CTG) interpretation: Some cases were found to have substandard clinical care in relation to intrapartum management. They involved a delay in decision to deliver based on misinterpretation of CTG. In one case a decision made by the labour ward registrar to deliver was overturned after discussing the case with the consultant. The panel felt that in this instance there was a need for improved communication between the medical team; had the case been discussed fully the decision by the registrar was unlikely to have been altered by the consultant. However in both cases it was judged that the failure to respond did not impact directly on the outcome as the infants were delivered in good condition

Management of diabetes (pre‐existing and gestational) was at times considered suboptimal. This included medication management, whereby insulin dosages were too cautious for pregnant women, resulting in elevated blood glucose levels. There was also a failure to follow the Trust’s diabetes guideline, as aspirin was not commenced at booking of some women with pre-existing diabetes. Infection screening: high vaginal swabs were not taken at the time of admission in women with preterm rupture of membranes or threatened preterm labour, which was against guidelines Lack of consideration for in‐utero transfers following admission to triage, whilst women were stable.

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7.3.3 Lack of clinical leadership

This was a persistent theme evident from initial resuscitation at delivery up to withdrawal of care. It was felt that the nursing/ANNP teams managed the neonatal care well but leadership from senior doctors was limited. This often left junior doctors unsupported and undertaking procedures in which they would have had little experience. As a result, management of care was often inconsistent and inappropriate. Advice, when sought from NICU (level 3) consultants, was repeatedly left until the infant was unstable and therefore unsuitable for transfer. Effective leadership from delivery would have ensured that infants were managed appropriately and the medical and nursing teams could work more effectively.

7.3.4 Inconsistent/inappropriate management plans. Evidence from the case notes suggested that there was a lack of experience in caring for babies delivered at very preterm gestations, including repeated attempts at intubation and lack of ventilation strategy. There was also evidence of inappropriate management plans resulting in substandard care.

7.3.5 Inappropriate transfer decisions ‐ this was a recurrent theme The panel felt that it is imperative that the Newborn Network Policy of transferring to appropriate level neonatal units is adhered to and that these infants are transferred at an optimal time and whilst stable. Six cases reviewed needed to be transferred out following birth rather than being retained and managed in a Level 2 unit (LNU). It was considered that appropriate transfer and management of neonates at very premature gestations might have resulted in a different outcome. The panel acknowledged that lack of capacity at the NICU (Level 3 unit) occasionally prevents timely transfer of eligible babies. However communication needed to be more robust to ensure that infants were transferred appropriately.

7.3.6 Medication management. Issues include inadequate dose of fluids given during resuscitation, advice sought appropriately from senior clinicians and pharmacists but not carried out, drugs being documented in the notes as given but not prescribed. There is also evidence of a lack of experience in caring for neonates delivered at early gestations.

7.3.7 Withdrawal of care. The panel felt that the decisions not to resuscitate, stop resuscitation, or withdraw care were at times made inappropriately, and this was again ascribed to a lack of clinical experience and leadership.

7.3.8 Clinical expertise/training. The panel felt that clinical expertise and training needed to be improved in order to be able to manage neonates at early gestations. Often, many attempts were needed to intubate by various staff members including consultants. The fact that the successful intubation was often achieved by a consultant with current experience of working in a NICU highlighted this issue.

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7.4 Grading

All grades were assigned by consensus

Table 7.4.1 summarises the substandard care grades (CESDI) for neonatal deaths

Grade

Level of care Neonatal

cases

0

No suboptimal / substandard care

1

1 Suboptimal care, but different management would have made no difference to the outcome

10

2 Suboptimal care; different care might have made a difference (possibly avoidable death)

4

3 Suboptimal care; different care would reasonably be expected to have made a difference (probably avoidable death)

1

Total

16

5 of the 16 deaths (31%) were considered potentially avoidable, but in 15 out of 16 cases, the panel identified concerns about the neonatal management of care. Some issues with obstetric care were identified but none were considered by the panel as relating directly to the deaths, and decisions to deliver were made appropriately. With the exception of one case all neonatal deaths occurred after preterm birth.

Table 7.3.5 shows the care grades during the four years of the review. In the last two years there was one potentially avoidable death (Grade 2), compared to 4 in the first two years of the review period

Table 7.4.2

Grade 2010/11 2011/12 2012/13 2013/14

0 0 0 1 0

1 2 1 3 4

2 1 2 0 1

3 0 1 0 0

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8. Sudden Unexplained Deaths in Infancy (SUDI)

8.1. SUDI cases

Eight SUDI cases met the inclusion criteria and all were reviewed.

All cases were born to white British, unemployed women, all but one of whom were smokers. With the exception of one case, all cases were born at mature gestations and with a birthweight above 2.5 kg.

There were discrepancies between birthweights being plotted on the customised birth charts and the WHO Child Health Record charts. When plotted on the Child Health Record charts, all birthweights were

above the 9th centile action line and therefore not managed on a high risk pathway. However 5 of the 8

cases (63%) were below the 10th customised birthweight centile and another one was on the 12th.

8.2. Panel reviews ‐ SUDI

Antenatal and postnatal care was reviewed but the cases were not graded.

There were generally no antenatal issues of note. Postnatally, it was observed that the majority had risk factors of maternal smoking (7 cases, 88%) and fetal growth restriction (5, 63%). In six of the cases the infants were either co‐sleeping or their sleeping position was noted as a possible contributor to the death.

SGA at birth was seen as an important precedent and risk factor. The panel felt it was important that the same weight standard should be used postnatally as during antenatal care.

It was recommended that a system should be in place whereby continued parent education is available and documented from birth, providing a record that mothers are being offered all available information on preventing SUDI’s.

The panel also stressed the importance of multi‐agency working and communication. In one case the woman denied any social issues at booking, and the community midwife knew at no point during the pregnancy that there was social services involvement due to a history of neglect, drugs, domestic violence and alcohol.

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9. OVERARCHING THEMES

9.1 Postnatal and Bereavement Care No specific issues were highlighted concerning postnatal care within the hospital. However postnatal records were missing in the majority of cases. Where they were available for review, women appeared to have been cared for and discharged appropriately. Maternal wishes were respected and there was involvement of relevant religious representatives. Bereavement care was undertaken by delivery suite and postnatal midwives as there is currently no specialised bereavement midwife in post.

Panel members felt that women as well as midwives would benefit from a specialised bereavement midwife who could co‐ordinate the care bereaved women and families received, ensuring continuity of care, appropriate involvement of agencies such as Stillbirth and Neonatal Death Charity (SANDS), ensuring mementos were handled sensitively, and also as support and educator for midwives. A bereavement midwife specifically trained in gaining consent for post mortems would help to increase the uptake of vital investigations such as chromosome analysis, skin biopsies and full post mortems.

9.2. Postmortems. The panel considered the uptake of postmortems to be poor: only 28 cases (42%) had a post mortem performed. Ten were coroner’s cases. It was also noted that placental histology in cases not undergoing postmortem was undertaken locally. The panel felt that it would be beneficial for the histology to be undertaken by a perinatal pathologist with expertise in perinatal postmortem examination. Such examinations are already funded under a regional contract so there would be no additional cost to the Trust.

9.3 Policies, procedures and guidelines. Walsall Healthcare NHS Trust has a generally comprehensive and up to date library of policies and procedures for both maternity and neonatal services. The following issues were identified: Management of the SGA fetus needs updating in line with RCOG guideline GT31, The Investigation and

Management of the Small for Gestational Age Fetus Guidelines involving serial scanning need updating Some guidelines (e.g. diabetes) were present and appropriate but were not being followed Guideline needed detailing criteria for transfer of neonates to Level 3 units,(NICU).

10. Trust based reviews

All cases reviewed here had also undergone “in house” review and discussion at the joint obstetric and neonatal morbidity and mortality meetings. Any cases identified as serious untoward incidents underwent a full root cause analysis. Any learning points from the reviews were discussed and plans for future pregnancies agreed.

A comparison of the Trust’s own review with the independent panel review did suggest that Trust reviews identified a number of deficiencies in cases with serious outcomes, and outlined plans for improvement. However important information became apparent through the independent structured review of the standard of care and avoidability of outcome, and led to the identification of additional key learning points and themes. Such insights, matched with subsequent action, are likely to help avoid recurrence of potentially preventable adverse outcomes.

The structured external review also led to a larger proportion of cases where the cause of death could be determined, compared to the in‐house reviews. The pie charts below illustrate this for the stillbirth cases, showing a reduction of the deaths remaining ‘unexplained’ from 31% to 9%.

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The need for enhanced audit and review processes for perinatal loss has been recognised by the NHS as a priority, and implementation of a standardised review process, accompanied by a network facilitated peer review quality assurance programme, will support the Trust in identifying and addressing any care issues.

Infection; 0; 0%

Abruption; 6;

14%

Cord accident;

1; 2%

WMH case reviews

Unexplained; 13;

31%

Placental

insufficiency; 1;

2%

Diabetes; 4; 10%

DFM; 7; 17% FGR; 10; 24%

Infection, 4, 10%

Cord accident, 1,

2%

Unexplained, 4,

10%

Abruption, 4, 10%

Panel Reviews

Placental

insufficiency, 1, 2%

Diabetes, 5, 12%

DFM, 0, 0%

FGR, 23, 54%

Fig 10.1 a & b Stillbirth categories according to in‐house reviews (top) and panel reviews (bottom). Panels identified a larger proportion of causes / conditions leading to death, resulting in fewer cases being categorised as

‘unexplained’. This was mostly due to more cases being identified as having fetal growth restriction.

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11. Learning Points

This review was able to highlight a number of system issues which were linked to adverse outcomes, and which need to be addressed to ensure provision of high quality, safe care.

Antepartum

Thorough medical and social risk assessment at the beginning of pregnancy is essential to ensure the

mother is receiving the appropriate care pathway. Furthermore, the circumstances and management plan need to be re‐evaluated by the lead professional at each visit, and documented in the notes even when there is no change

Women should be educated about the significance of reduced fetal movements and encouraged to present early to the maternity services if concerned

More appropriate involvement of senior clinicians with high risk cases

Skillset for antenatal surveillance of fetal growth needs to be enhanced, with care following evidence based protocols ‐ a. for low risk pregnancy, serial fundal height measurement and plotting on customised charts, and

referral for further investigations as indicated. b. for pregnancies at increased risk, or where fundal height measurements are unreliable, the

institution of a serial scanning protocol according to RCOG guideline

Intrapartum

Enhance and maintain skill‐set in assessment and interpretation of fetal heart rate tracings.

Maternal medical conditions, particularly hypertension and pre‐eclampsia need to be assessed and an appropriate plan of care documented

Adequate surveillance during labour needs to include timely escalation of any problems

Postnatal care:

Community midwifery postnatal documentation needs to be retrieved and incorporated into to the

hospital case notes

Effective follow up from both obstetric and neonatal teams, with provision of appropriate management plans for future pregnancies and letters documenting discussions and plans

Need for a professional, dedicated bereavement service to:‐ a. ensure appropriate support for the mother before and after discharge; b. training and supporting midwives in caring for bereaved families; c. obtaining informed consent for post‐mortems; d. ensuring that appropriate tests are carried out and the perinatal death checklists are completed

fully; e. ensuring that a postnatal consultant appointment is offered to all bereaved women with plan of

care for next pregnancy.

Neonatal Care:

Consultant Paediatrician with overall responsibility for the management of each neonatal case needs

to ensure that teams understand the individual plans of care

Neonatal leadership needs to be clearly defined

Communication and co‐operation with adjacent Level 3 unit (NICU) needs to be enhanced. This should include keeping a record all network communications to ensure quality control

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A clear guideline for the transfer of neonates needs to be formulated in conjunction with the Neonatal Network

Resuscitation and medication management needs to be regularly audited and training needs reviewed

Neonatal weight needs to be assessed using customised birthweight centiles in continuum with antenatal assessment, to avoid confusion and ensure that SGA/FGR neonates are recognised and cared for on an appropriate postnatal pathway

Infants (SUDI):

There needs to be a clear pathway by which care is transferred between professionals, enhancing

channels of communication

Administration of all SIDS prevention information needs to be well documented

Multidisciplinary team working and referrals to aligned services such as smoking cessation, mental health services

Findings from Child Death Overview Panels should be made available to all stakeholders involved in the care

General

Multidisciplinary programmes of learning are an important way to strengthen interdisciplinary

relations and communication Clinical leadership structures should be reviewed to ensure safe, accountable maternity and neonatal

care; consultants and midwives with overall responsibility for the management of each case need to ensure teams understand the individual plans of care

Standards for documentation need to be improved, including drug prescriptions and clinical records

Perinatal postmortem and placental histopathology should be performed by specialist perinatal pathologists, utilising regional services

Review processes

There is a need for a programme of standardised reviews of perinatal deaths, combined with network facilitated peer review, to enhance learning from adverse outcome and development of action plans to address system failures and enhance patient safety.

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12. Summary and Recommendations

This enquiry was a comprehensive independent review of stillbirths, neonatal deaths and sudden unexplained deaths in infancy which occurred over a four year period, and represents an in‐depth examination of associated factors and underlying causes of such deaths.

The findings need to be seen within the context of a busy NHS hospital, where most episodes of care lead to a satisfactory outcome, despite a challenging maternity population. The proportion of deaths associated with substandard care are in keeping with other case reviews, including West Midlands regional confidential enquiries undertaken by the Perinatal Institute [1] and the recently published national report on stillbirth at term by MBRRACE [2]. In each case, over half of the deaths had substandard care which was considered to have affected the outcome, which was higher than observed here.

Nevertheless, the finding suggests that many adverse outcomes are potentially avoidable, and raises a number of important learning points which we have summarised.

These points have implications for all stakeholders tasked with the commissioning and provision of good maternity care in Walsall. We list below a number of points which we recommend for consideration

12.1 Trust ‐ Maternity

a. Increase awareness of importance of antenatal assessment and clear, individualised care plans

reflecting medical, obstetric and social risk factors b. Ensure all staff are trained in antenatal surveillance of fetal growth and the appropriate referral

pathways, and establish rolling audit of performance (SGA/FGR detection rates)

c. Ensure ongoing training in intrapartum surveillance, CTG interpretation and timely escalation of problems

d. Establish a dedicated diabetes in pregnancy service including a diabetes specialist midwife post e. Establish a post of a bereavement service with specialist bereavement midwife f. Use the regional perinatal pathology service for placental histology g. Ensure clear and contemporaneous record keeping at all times

12.2 Trust – Neonatal

a. Consultant paediatrician needs to have overall responsibility for the management of each

neonatal case ensuring teams understand individual plans of care b. Ensure adherence to protocol re transfer of preterm infants c. Enhanced communication and co‐operation with Level 3 unit,(NICU); interactions and outcomes

of transfer requests should be recorded to allow audit and review d. Growth status of neonates at delivery should be assessed using customised centiles consistent

with obstetric and midwifery policy

____________________ 1. Confidential Enquiries – West Midlands Perinatal Institute 2007-2011

www.pi.nhs.uk/pnm/clinicaloutcomereviews/index.htm

2. Perinatal Confidential Enquiries – MBRRACE-UK 2015

www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Perinatal%20Report%202015.pdf

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12.3 Trust – General

a. Implement a self‐sustaining process of standardised reviews of all perinatal deaths to allow

ongoing learning from adverse outcomes and facilitate prevention

12.4 Maternal and Newborn network

a. Clarify transfer protocols between local neonatal unit (LNU) and neonatal intensive care unit

(NICU); facilitate collaboration b. Help standardise assessment and management of neonates c. Provide support and mechanisms for the professional development and maintenance of

competence and expertise of medical staff at LNUs and special care units through collaborative learning and working

d. Facilitate standardised peer review of adverse outcomes at network level

12.5 Clinical Commissioning Group

a. Provide oversight and quality assurance for antenatal risk assessment as key determinant for the

maternity payment pathway, allowing for prevalent medical, obstetric and social circumstances of the maternity population

b. Ensure that sufficient resources are available for fetal growth assessment by ultrasound, according to RCOG and NHS England commissioning guidance

c. Allocate funding for a dedicated bereavement service to optimise the care of women and families who have had a perinatal loss

d. Support implementation of standardised reviews of adverse incidents

12.6 Walsall Council and Public Health

a. Promote public health messages relating to maternity care, including smoking and obesity b. Promote education on SIDS awareness including co‐sleeping, alcohol, smoking, restricted fetal

growth c. Maintain clear pathways for interagency working with high risk families d. Ensure feedback from Child Death Overview Panel reviews are shared with all agencies involved in

the care e. Address service provision within areas of high deprivation

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13. Stakeholder Responses

Drafts of the report were presented for discussion and subsequently circulated to 1. Clinicians from Walsall Healthcare NHS Trust, 2. Walsall Borough Council & Public Health, and 3. the Clinical Commissioning Group, with an invitation to respond and comment on the findings.

Below are their respective responses.

13.1 Walsall Healthcare NHS Trust

We would like to thank the perinatal institute for their review into perinatal deaths and maternity care at Walsall Healthcare NHS Trust. We have reviewed the content and wish to submit the following response.

General overview

The audit was from 2010 until 2014. Since 2011 the maternity unit has been using BadgerNet (IT system). This is illustrated in the report as causing confusion with documentation between ‘paper’ records and an IT system. We believe that the reviewer did not see all our IT information in relation to the cases under review as the audit was conducted off‐site. All the references to ‘missing’ documentation may not be correct for cases reviewed after 2011.

PI Comment: The reviewers had access to available records including those printed out from the IT system. However there may have been inconsistencies in documentation during the change over which took place during the period reviewed.

The birth to midwife ratio is 1:38 (budget) with use of bank staff (our own staff) currently equates to 1:35

The Trust has committed additional resources to maternity to improve this during 2015/16.

We believe we use the SCOR process at our RCA’s apart from the grading (as we do not have the software). We have been using a national tool (Wigglesworth and ReCoDe) so although the report states we have a higher group of deaths in the ‘unknown’ category this is not correct. In Wigglesworth there is no classification for IUGR so we reclassify.

Obstetric

6.3.2 The maternity It system puts patients onto a pathway according to their need i.e. high risk/low risk against national indicators. A recent independent report by another reviewer using the BadgerNet system supports the evidence that women are on correct pathways. Previous to BadgerNet we used a paper risk assessment which was agreed with the consultants and very ‘risk adverse’. We have had several external audits that have recommended that more women should be on low risk pathways; this is in conflict with the findings of this report. The reviewer could have asked us for information on where to find the risk assessment.

PI Comment: We acknowledge that changes in risk assessment have been made during the period reviewed. However the majority of cases were from before these changes have been fully implemented.

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6.3.3 Diminished fetal movements (DFM) are an issue we are aware of. All of our information booklets contain information for women regarding DFM. This information has been in consistent use since the implementation of the use of the perinatal notes. We have also had posters put up in GP surgeries and children’s centres relating to this. All community midwives discuss this throughout pregnancy. It is the most common admission reason for self‐presentation at triage. Since 2011 this has been recorded on BadgerNet. The reviewer did not access the BadgerNet system for this review.

PI Comment: The observation about DFM in the report was based on the hand held notes as well as the provided print outs from the IT system.

6.3.4 We have a KPI attached to the detection of IUGR (64%) in December it was 75.5, January 84.7,

February 85.7. Please note that the software the perinatal institute uses to identify IUGRs was only

available to the Trust from October 2014. We have robust pathways in place for the management of

IUGR. The statement that we do not follow RCOG guidance is incorrect. Our policy is based on RCOG

guidance. RCOG guidance details the management once IUGR is detected but NOT how often you scan

prior to detection of IUGR.

PI Comment: The review includes cases where the current scanning policy did not identify growth restriction in at‐risk cases and refers to new RCOG guidelines which recommend regular serial scanning up to delivery

Page 15 paragraph 4. What is the significance of this? We have a Patient Group Direction (PGD) for

syntometrine and it is recorded on the delivery sheet.

Page 16 fetal movements (response as above) referral is made automatically to the smoking cessation team (this is a KPI) and also mental health is a consultant referral letter to the GP. The documentation relating to this is on BadgerNet.

PI Comment: The review referred to inconsistencies in the documentation of referrals made

Neonatal (Section 7)

Section 7.3.3 Leadership

Not demonstrated in the notes however we have in place:

Neonatal Consultant of the week (NCOW) system has been in place since 2011. So the NCOW

takes the overall responsibility for the care of babies during the week. Management plans are

entered on neonatal BadgerNet.

Inappropriate transfer decisions

We are part of the SSBC neonatal network and we follow their guidelines. We have received

feedback from our annual network meetings that we are compliant with the transfer policy. Any

non‐adherence to the policy (for capacity reasons) is discussed with the level 3 unit. Historically

this was not documented but was recognised practice within the network.

Clinical care/expertise

We are a level 2 LNU without a split rota for paediatrics/Neonatal care. This is a national issue. We are addressing the needs of our patients by:

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Working towards provision of a split rota.

introducing Neonatal peer review

Mandatory participation in network programme for consultants covering LNU which will include

different aspects of management of sick neonates, skills training like difficult airway management,

leadership and communication skills

Introduction of video laryngoscope, colour capnography and laryngeal mask airway for

management of babies with difficult airways

Adherence to protocol of transferring preterm infants

‐ Use of Network Proforma for exception reporting. These are audited at Network.

Enhanced communication and co‐operation with level 3 unit, interaction and outcome of transfer

request will be audited and reviewed.

Clear documentation of any discussions with a level 3 unit regarding on going

management/careplans for any challenging babies that are extremely sick or premature.

Section 8 ‐ SUDI

The child health charts are national charts we have no influence over their use. This would not be unique to

Walsall, so in effect we are not doing anything outside of national practice. Could this be stated please?

Pi Comment: We have highlighted this issue within the context of the case reviews as they are relevant locally, as the inconsistencies could be addressed through Trust policy. However we agree that this is also a national issue and are working to address it through appropriate channels.

Section 9 (overarching themes)

9.3 Policies and procedures First 2 guidelines we believe are current and based on RCOG guidance. The transfer guidance followed for

transfer to a level 3 unit, (NICU) is SSBC regional guidance that we adhere to.

Section 10 Trust based reviews

Charts identifying case reviews are covered in above point relating to SCOR and Wigglesworth. We intend

to move towards using the SCOR software.

Section 12 summary and recommendations Many of these are already in place although we accept were not clearly evident in the case notes reviewed. This will form our forward audit programme and improvement action plan.

Trust Response collated from

Mrs Arundhati Mulay – Clinical Director for obstetrics & Gynaecology

Mr Anjan Bhaduri ‐ Clinical Director for Paediatrics & Neonates

Mr B.J. Muhhammad – Consultant Paediatrician

Mrs K Palmer – Head of Nursing & Midwifery

Further written feedback on the report was received and incorporated into the response from: Mrs C Hollington – Matron for Quality & Governance Mr J Davis ‐ Consultant Obstetrician & Gynaecologist Mr J Pepper ‐ Consultant Obstetrician & Gynaecologist Mrs T Roberts – Matron for Delivery suite

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13.2 Walsall Metropolitan Borough Council and Public Health

We would like to thank the West Midlands Perinatal Institute for their review into perinatal and infant deaths in Walsall. Walsall MBC remains committed to ensuring that all children in Walsall have the best possible start in life, and as such, high levels of infant and perinatal mortality in Walsall are a significant cause of concern.

The reduction of infant and perinatal mortality rates has been identified as a key priority by both the Health and Wellbeing Board and Children and Young People’s Partnership Board in Walsall. The findings of this review throw further light on the contributory factors to infant and perinatal mortality in Walsall.

Walsall Public Health has been actively working implementing the recommendations of the review, including the promotion of public health messages in pregnancy and raising awareness of SIDS. Walsall Public Health will be working closely with partners to ensure that the recommendations of this review are used to drive forward improvements in the care offered to mothers and their babies in Walsall.

13.3 Walsall Clinical Commissioning Group

The commissioned Perinatal Institute Report highlights a number of contributory factors which may impact on infant perinatal and infant mortality and provides a sound evidence base on which to improve outcomes for infants and families in Walsall. As part of our Commissioning Strategic Plan, Walsall Clinical Commissioning Group has identified the reduction in Infant Mortality for Walsall Children as a priority going forward and have reviewed WCCG recommendations within the report to ensure they are actioned appropriately and robustly. As lead commissioner we will seek assurance and evidence that all other recommendations are taken forward and will continue to work through our partnership arrangements with providers and other commissioners of care to ensure the best outcomes for Walsall families.