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Confidential case reviews of neonatal deaths: substandard care factors and upstream causes
  1. F Cross-Sudworth,
  2. L Ecclestone,
  3. A Williamson,
  4. J Gardosi
  1. West Midlands Perinatal Institute, Birmingham, UK


Objective To present the preliminary findings of a rolling confidential enquiry programme into neonatal deaths being undertaken on behalf of Safeguarding Children Boards.

Method The subject of the enquiry are all neonatal deaths which occurred in a PCT cluster between April 2008 and March 2010, excluding congenital abnormalities and deaths before 28 weeks. Anonymised case note review was undertaken by independent, multi-professional panels constituted of clinicians who had not been involved in the care of the cases.

Results 26 deaths have been reviewed to date. The review panels identified significant sub-optimal care factors in 25 of the cases, including: (1) inadequate management plans for pregnancy (17/26), (2) lack of identification of social or psychological factors requiring referral (15/26), (3) substandard antenatal care, including poor risk assessment or inadequate surveillance of fetal growth (17/26), (4) neonatal resuscitation not following NLS guidelines (17/26) and (5) frequent gaps in documentation (24/26). In 19 cases (76%) panels concluded that different management may have potentially avoided the adverse outcome. A review of units' own internal assessments of these cases showed wide variation of in house methods used for evaluation, with important learning points being missed.

Conclusion Many neonatal deaths are associated with substandard care which often originates with missed warnings in the antenatal period. It is essential that in house review of such losses are standardised and allow an open, multidisciplinary examination of the case and formulation of action plans for implementation. Independent confidential reviews can add important considerations and quality assure the process.

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