Over 900 babies born in 2015 died or were seriously brain injured due to mistakes during labour

The Royal College of Obstetricians and Gynaecologists (RCOG) is working through it’s “Each Baby Counts” project to try to reduce this number by 50% by 2020.

Of the 921 babies whose cases were reported to the project 655 (71%) had cerebral palsy, 147 (16%) died in the neonatal period due to injuries which, if they had survived, would have resulted in severe cerebral palsy, 119 (13%) were stillborn as a result lack of oxygen before delivery.

The Each Baby Counts project


The RCOG while emphasising that the vast majority of women receive excellent care during pregnancy, labour and delivery accepts that the consequences of stillbirth, neonatal death and brain injury are profound and effect not only the baby but the entire family. The failings in hospital investigations cause further emotional pain and uncertainty with parents often being told that the cause of their babies injury is unknown or possibly genetic when, in truth, the cause is a failing in obstetric and midwifery care.  The RCOG also recognises the financial costs to the families and to the NHS in meeting the needs of the injured children. Finally the RCOG is concerned with the emotional effect on the medical staff.


  1. Ensure all babies whose cases meet the criteria have the circumstances of pregnancy, labour and delivery investigated.
  1. Invite parents to participate in the process.
  1. Analyse all hospital investigations into stillbirth and brain injury in babies at term.
  1. Identify systemic causes of obstetric and midwifery mistakes (rather than individual failings).
  1. Make recommendations on how to improve practice at a national level and so reduce the numbers of babies injured and killed by failings in obstetric and midwifery care.

Initial findings

The initial findings looked at the standard of investigations rather than the underlying cause of the babies injuries.  Serious failings in the treatment of parents and in the standard of hospital investigations into stillbirth, neonatal death and brain injury caused at around the time of delivery were identified.  For example of those cases which were first referred to the programme 27% of 204 investigations reviewed were found to be of poor quality. In almost 75% of 599 cases reviewed parents were not involved in any meaningful way.

Richard Money-Kyrle, medical negligence solicitor at Boyes Turner,  comments:

“Having acted on behalf of cerebral palsy sufferers for 20 years it beggars belief that it is only now that the RCOG is putting in place a robust and open reporting system.  The information the RCOG is looking for has been available for 20 years through cases investigated by solicitors on behalf of families and children with cerebral palsy.  However the approach of NHS Trusts and the solicitors they instruct has been to deny responsibility, delay and minimise compensation payments.  Now patients have a legally enforceable duty of candour which requires medical professionals to tell the truth.  The enforceable duty of candour combined with the genuine and heartfelt compassionate driving force of Dr David Richmond the President of the RCOG and in a separate but related development Baroness Cumberlege (our news item 9 June “Rapid resolution scheme for babies who incur avoidable harm back in the news”) seems to be leading to a real effort to both reduce the numbers of babies injured by negligent care and to help the babies and their families.”   

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