Improvements needed in baby death investigations

Improvements are needed in the way the deaths of newborn babies in Scotland are investigated, a review has found.

Scottish ministers ordered the review of neonatal death rates after two spikes over a six-month period in 2021/22.

It found that no new or unusual causes of death, or systemic failures of care, were to blame.

But Healthcare Improvement Scotland said more comprehensive reviews of neonatal deaths were needed.

The review, by Dr Helen Mactier, a retired consultant neonatologist, found an estimated 30 additional deaths of babies within 28 days of birth in 2021/22 when the data was compared to the previous four years.

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Dr Mactier found "significant variation in the quality of local review reports into neonatal deaths" across Scotland which is likely to have resulted in missed opportunities for learning.

She said: "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. This review has helped to get a clearer understanding of the increase in neonatal deaths that occurred in 2021/22."

The increase in baby deaths in Scotland during 2021/22 was high enough to trigger an investigation

The review found one of the factors behind the spike in deaths was more babies than expected were born before 28 weeks in 2021/22.

Babies born before 28 weeks' gestation have a higher neonatal mortality rate than babies born later in pregnancy.

There was also a significant increase in the neonatal mortality rate for babies born between 32 and 36 weeks' gestation.

Ten of the 25 babies born at this stage of pregnancy had a congenital condition "incompatible with survival".

However, the data available did not allow the review to determine if this reflected a change in the incidence of congenital conditions, or a change in the management of babies affected by these conditions.

The impact of Covid

The review did not find evidence of systemic failures of maternity or neonatal care or unusual factors to explain the increase in neonatal deaths in this period.

The Covid pandemic may have been a factor in the increased deaths but it was not possible to say with certainty, according to Dr Mactier.

The report points out that in 2022/23, the neonatal mortality rate in Scotland returned to that observed between 2015 and 2020.

However, it has since increased.

National Records of Scotland data shows that in the three months to September, 2023 there were 3.4 deaths per 1000 live births, higher than the quarterly rates recorded in the period covered by the review.

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