Failures in Gloucestershire’s neonatal care led to baby’s deaths

The deaths of nine babies could have possibly been prevented if not for “missed opportunities” in their neonatal care, a report has revealed.

According to an external review, a total of 44 babies died during labour or after birth at Gloucestershire Hospitals NHS Trust between 2020 and 2023.

Of those, nine deaths warranted a review by an internal scrutiny team – which external investigators said appeared to “underestimate the failings in care”.

The trust said it had since made significant progress in maternity services, including recruiting more staff and improving risk assessments.

The report cited gaps in documentation, incomplete risk assessments, delayed escalation processes and a failure to adhere to national guidance.

None of the 10 babies who died before 28 weeks gestation were felt to be avoidable, the report added, due to genetic conditions that affected their survival or severe and unpredictable complications during pregnancy.

The review, published on Monday, found the trust conducted incomplete risk assessments during pregnancy – particularly around reduced foetal movements, safeguarding referrals, and foetal growth monitoring.

During labour, neonatal teams misinterpreted or delayed calling for senior review where foetal heart rate monitoring suggested a baby needed urgent intervention.

For at least half of the babies who died, there was a “lack of a clear decision making and documentation” around transfer to a more appropriate unit, despite there being opportunities to do so.

The report stated the quality of the subsequent internal investigations did not meet the best practice standards of the national Perinatal Mortality Review Tool (PMRT).

The majority of the reviews did not involve professionals from outside the trust to provide external scrutiny. In some cases, clinicians involved in the incident were actively participating in the review.

“Care grading often appeared to underestimate the missed opportunities and failings in care,” the report read.

“Action plans inadequately responded to the issues in care and rarely had time frames and feedback mechanisms to ensure they had been completed”.

However, the report added “many areas of good care were identified”, and there were no concerns over recurrent poor practice from any members of staff.

Examples of “compassionate debriefing” were also seen, with emotional support provided to bereaved families by specialist teams.

“Since these babies died, Gloucester Hospitals NHS Foundation Trust have taken steps to address the previous failings in care and some of these recommendations may already have been addressed,” it said.

The trust says it has since made significant progress in maternity services, including recruiting more staff, improving risk assessments and providing electronic access to maternity notes.