Deaths of newborn babies should be more thoroughly investigated by health boards in Scotland, experts have said after reviewing an increase in infant mortality.
The team found inquiries into baby deaths conducted by health boards were “poor quality, inconsistent and incomplete”.
The experts added that information about staffing levels on maternity wards at the time of the deaths was so poor that they could not draw any conclusions.
They were also unable to determine if health boards enlisted independent, external advisers when considering if deaths could have been prevented.
The report found, however, that no new or unusual causes of death, or systemic failures of care, were to blame for the rise.
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Helen Mactier, a retired neonatologist and chairwoman of the Neonatal Mortality Review, said: “This review has helped to get a clearer understanding of the increase in neonatal deaths that occurred in 2021-22.
“We understand that there are still unanswered questions, and our recommendations are focused on ensuring that future opportunities to learn are not missed and acted on in a timely and comprehensive manner.”
In September 2021 and March 2022, a rise in the number of neonatal deaths in Scotland breached warning limits and ministers commissioned Mactier’s investigation.
Her team found that the number of newborn babies who died between April 2021 and the end of March 2022 was 29 per cent higher than expected. There were 135 deaths, compared to the 105 which might have been anticipated based on previous years.
Their final report says the review did not uncover systemic failures in maternity or neonatal care in Scotland, nor was there a cluster of cases linked to a particular cause which could explain the problem.
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However, NHS Fife was highlighted for having a newborn death rate at least five per cent higher than similar units across the UK. When the experts looked at the health board’s reviews of such deaths, they felt it underestimated the implications of what had happened.
The review panel held a meeting with the board in which they discussed upgrading the cases to a higher score, better reflecting the need for improvement.
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Mactier said NHS Fife should already be looking at its own data and considering what was happening in their maternity and neonatal units.
Gaps in the information covered by neonatal death reviews in NHS Grampian, where the number of cases had increased, was also raised in the report.
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Mactier said: “Across the picture there were some instances of the reports which were not as thorough as they might have been.”
In England detailed investigations have been conducted into maternity services in East Kent and Shrewsbury and Telford NHS trusts. Similar investigations have not been launched in Scotland, although Mactier, who was involved in the East Kent investigation, said she felt scrutiny of services in Scotland did not lag behind other parts of the UK.
Her report noted there was a particular increase in baby deaths where mothers were expecting more than one baby during 2021-22. The number of deaths was almost double the figure seen in the previous four years and was linked to the children being born very premature.
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There was also a small increase in placenta, cord and membrane complications, along with other problems encountered at delivery.
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The report also notes fewer babies being lost late in pregnancy and more babies being born very early and offered care, is partially linked to the rise in newborn death rates.
Mactier said: “The death of a baby is a devastating and traumatic experience for parents and families. Although increasingly small and sick babies now survive, there will be some babies for whom this is not the case. This does not necessarily reflect any shortcomings in care.
“However, it is important to acknowledge that some deaths may have been preventable. To prevent as many baby deaths as possible, review of both maternity and neonatal care is an essential part of midwifery, obstetric and neonatal practice.”
The report has called for a quicker response to increases in neonatal deaths at local and national levels in Scotland and for reviews of cases to be conducted in a more robust and timely manner. It notes suspending of data collection around staffing levels was affected by redeployment of personnel due to the coronavirus pandemic.
The minister for public health and women’s health, Jenni Minto, said the government accepted the recommendations of the report.
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“The review was commissioned so that we could better understand what may have caused the increase in neonatal mortality and to find ways that we can improve learning and future care. The findings made will now be considered carefully and we will work with Healthcare Improvement Scotland and other NHS partners on the next steps,” she said.
“We recognise the tragedy of losing a baby and the impact this report may have on grieving families and would encourage those who need additional support to get in touch with Sands’ or one of the other baby loss charities who provide bereavement support.”
A spokesman for NHS Fife said: “While neonatal deaths in Fife remain rare, we appreciate that it is devastating for the families involved. During 2021 we saw an unexpected rise in neonatal mortality in Fife, which has reduced significantly in the period since.
“Patient safety is our single biggest priority and the report notes no single cause for the rise in neonatal deaths reported across Scotland.”
