Investigating baby deaths: a guide for bereaved parents

How Is The Death Of A Baby Investigated?

Much depends on the timing of the death and how it is classified. Where a baby dies before 24 completed weeks of pregnancy, it is termed a miscarriage or late foetal loss.

Death after 24 completed weeks of pregnancy, where the baby did not, at any time, breathe or show signs of life, is termed a stillbirth. It can occur while the foetus is in the womb, or during labour or delivery.

Sometimes the cause is unknown.

Blood tests, tests for infection and histology can all be used to build a picture of the cause of death.

Will a Post Mortem Help?

Written permission is required where there is no live birth. It can involve examining organs in detail, looking at tissue and blood samples and carrying out genetic testing.

Post-mortem is useful for determining cause and is heavily relied on by Neonatologists in order to predict what would have been in the absence of negligence. What should have been seen/noted? What signs were there?

Investigations

The Perinatal Mortality Review Tool (PMRT), is designed to assist the hospital in investigations at 22 weeks of gestation, including late miscarriages, stillbirths and neonatal deaths. All stillbirths should be reviewed by the hospital.

The aim is to provide answers for bereaved parents, whether anything could have been done to prevent the death and identify any ‘avoidable’ harm.

It should support standardised mortality review across maternity and neonatal units in the UK and encourage local and national learning from review findings to improve care.

The review team will;

• Review the medical records of the mother, tests and results and any post-mortem, if that is something that has been consented to

• Speak to the staff involved in the care

• Speak to the parent(s) and address any questions or concerns

• Consider local and national guidance and policies and check whether it was departed from

• Consider the quality of bereavement care (a helpful resource for families is National Bereavement Care Pathway | Sands - Saving babies' lives. Supporting bereaved families.

• Provide the parent(s) with a key contact

It can take several weeks or months to complete. There will be a hospital review meeting where any questions can be raised, but the parent(s) cannot attend. On completion, there is an opportunity for a discussion with a senior clinician.

The Findings

In the event of ‘inadequate care’ there will be a set of actions raised to prevent future harm. The hospital has a ‘duty of candour’ to be honest and open about these mistakes. A finding of a ‘mistake ‘will lead to another investigation, namely a Patient Safety Incident Investigation (PSII).

This investigation is carried out by the care provider and is not independent. A review of the maternity notes will involve an external specialist. The outcome should be a report detailing actions to prevent the same thing from happening to someone else.

After the report has been produced, there is an opportunity for a meeting with a senior clinician.

Before any meeting, it is often helpful for families to receive a copy of the report by post or email to allow them time to digest it. These cases are sensitive and families report that it is not easy to take everything in. For this reason, the parent(s) may wish to ask for permission to record a meeting

If you do not feel that all the concerns have been answered, you have the right to complain.

Health Services Safety Investigation Board (HSSIB)

The Maternity and Newborn Safety Investigations (MNSI) programme investigates certain cases of early neonatal deaths, intrapartum stillbirths and severe brain injury in babies born at term following labour and maternal deaths.

They will investigate babies born following labour after 37 weeks and for 7 days of life. That includes stillbirths during labour but not if they were born by caesarean section, without labour. It will not be used where there is a congenital abnormality or health issues that have caused the death of the baby.

The reviews are independent.

The Shortcomings

Despite the existence and purpose of these tools, families often report to me a lack of communication and clear explanation. It would be good to know whether the actions that are highlighted to make improvements have been done.

The biggest criticism that I hear by mothers is that they are not listened to during maternity care. It is a common theme as reported in the Birth Trauma Inquiry Report for publication in May 2024

During the litigation process, the Trust should respond to a claim within 4 months and 21 days with a reasoned response. Trusts differ in their approach, but I have experienced significant extension requests, even against a background of concessions, identified mistakes and investigations. Delay does not help families to move forward.

Another observation is that psychiatric and psychological services differ significantly. There are often huge waiting lists and a lack of support. Many families lack the financial resources for private treatment. It is astonishing that prompt provision of care is not made when mistakes have been conceded, negligent or not. Delays and a lack of compassion only add to the pain for grieving families.

In my experience, there would be less recourse to the legal process if an apology, investigation and explanation were offered sensitively and consistently with evidence of changes that have been made to prevent the same thing from happening again.

What can the Legal Process Offer?

It may lead to greater understanding, a voice, and sometimes an apology. It will lead to compensation for your loss and with it access to treatment. It should contribute to change.

The Cornwall Hospitals NHS Trust took a progressive approach in a case reported in 2022. It acknowledged its mistakes, issued an apology and confirmed what changes had taken place. The parents were informed that the loss of the baby would lead to a change, including the introduction to annual training.

How Forbes Solicitors Can Help You

At Forbes Solicitors, we are committed to raising awareness of the ongoing crisis within the maternity care sector of the NHS. We encourage those impacted by these failures to share their experiences; your voice matters. Telling these stories is crucial in driving the reforms necessary to prevent future harm. We stand with each family seeking answers. If you need support or want to understand your options, call us in confidence on 0800 037 4625.