Hospital trust 'deeply sorry' over baby deaths

Perinatal death rates at the trust were above the national rate, but are now below it

A hospital trust has said it "could and should have done better" after a review into more than 150 baby deaths found “care issues” which may have affected losses of life.

Details of a new report from the University Hospitals of Derby and Burton NHS Foundation Trust into perinatal deaths have been revealed by the Local Democracy Reporting Service.

The review was triggered last year by the trust having perinatal mortality rates significantly above the national rate, which have now fallen to below the national average.

Sarah Noble, director of midwifery, said: "We remain deeply sorry to the families that we let down across the time of this review."

Changed the outcome

Perinatal deaths include babies from the start of pregnancy up to the age of one, largely made up of stillbirths and complications during pregnancy and birth.

The report detailed 168 perinatal deaths which occurred at the trust between January 2020 and March 2023.

99 related to stillborn babies, 56 neonatal baby deaths - in the first 28 days of life - and 13 “late fetal losses”.

Of the 168, 11 babies were born at the trust but died elsewhere after being transferred, and the report focussed on the remaining 157.

In a number of the cases reviewed “care issues” were identified which “may” or were “likely” to have changed the “outcome” for the babies who lost their lives.

The report also found 24 families, all in 2020, were not contacted to take part in reviews relating to their baby’s death.

The trust said it has now been in touch with them to apologise and see if any lessons can be learned from their cases.

The review also looked at cases at Queen's Hospital in Burton, as well as the Royal Derby Hospital

The report, carried out by an independent midwife, said: “Whilst there are many opportunities for sharing learning across maternity services the learning is not necessarily embedded into practice.

“This is reflected in the recurrent themes identified in this report, including fetal monitoring interpretation, women reporting reduced fetal movements and subsequent care, documentation, and communication issues.”

The report found a consistent failure to follow local or national maternity guidelines across all parts of the service, which the trust said it had corrected.

This included the trust saying it was compliant with a national “fresh eyes” policy to check the baby’s heart rate every hour during labour, when it was only checking every two hours.

It said the most common theme in the pregnancy stage was the management of women who reported reduced fetal movement.

It stated there were shortfalls in the lack of risk assessments, referrals for ultrasound scans, infrequently offering information on inductions, and providing information in additional languages.

The report said concerns raised by women whose babies had died included screening not being performed, birth planning advice given by junior medical staff, and lack of compassion after birth.

On Thursday, the NHS regulator said maternity failings at hospital trusts were becoming more widespread.

Sarah Noble, director of midwifery, said: “We have made significant improvements to our maternity and neonatal services, and are providing safer care than we were 18 months ago, with better outcomes for mothers and babies.

“Our compliance against national maternity safety standards has improved and we have invested in more staff, training and equipment and are involving families in the changes we are making.

“While we have made progress, we are not complacent, and our teams remain focused on delivering safer, personalised and professional care to every family using our maternity services now and in the future.”

The trust’s maternity units at the Royal Derby Hospital and Queen’s Hospital in Burton had been rated “inadequate" following inspections from the Care Quality Commission (CQC) in August 2023.