Led by the MBRRACE-UK team at the University of Leicester, this report details the findings from review of 130 term stillbirths, of which 85 were examined in detail by a panel of clinicians including midwives, obstetricians and pathologists.
The enquiry found that half of all term, singleton, normally-formed, antepartum stillbirths had at least one element of care that required improvement which may have made a difference to the outcome. Opportunities missed in two thirds of cases included: correctly identifying women with risk factors for diabetes and offering them testing; and appropriate screening and monitoring the growth of the baby. Almost half of the women had contacted their maternity units with concerns that their baby's movements had slowed, changed or stopped. In half of these cases there were missed opportunities to potentially save the baby including a lack of investigation, misinterpretation of the baby's heart trace or a failure to respond appropriately to other factors. Internal hospital reviews were only documented for a quarter of the deaths and their quality was highly variable. A post-mortem was carried out in only half of the cases, but most were of satisfactory or good quality. A generally good standard of bereavement care was provided for parents immediately following birth, including the offer of the opportunity to create memories of their baby. Read the full report for the detailed findings and the key actions for improving services to help prevent the terrible heartache experienced by three families every day across the UK. Follow us on Twitter @TIMMSleicester@mbrrace