Baby deaths Scotland: 'Unanswered questions' remain following report into neonatal deaths spike

Healthcare Improvement Scotland has called for improvements in the way neonatal deaths are reviewed, after finding “unanswered questions” in their investigation into a spike of baby deaths in Scotland.

There are still “unanswered questions” relating to a rise in baby deaths in Scotland between 2021 and 2022, health watchdogs have claimed, after they called for improvements in review systems into neonatal deaths.

Healthcare Improvement Scotland (HIS) investigated the issue after two rises were recorded in September 2021 and March 2022. A total of 29 infants died.

According to HIS, the investigation “has identified various factors that appear to have contributed to the increase, rather than one single identifiable cause”.

There was a significant increase in the neonatal mortality rate for babies born at 32-36 weeks’ gestation in Scotland in 2021/22.

The report recommends greater collaboration across NHS boards and national organisations, along with earlier and more comprehensive reviews of neonatal deaths to ensure timely identification of potential issues.

The review’s authors, led by retired consultant neonatologist Dr Helen Mactier, said they found variations in the quality and detail of local case reviews, as well as incomplete data around staffing levels during the pandemic.

The number of additional neonatal deaths in Scotland in 2021/22 compared to the previous four years is estimated at 30, the report states. More babies than expected were born before 28 weeks’ gestation in Scotland in 2021/22.

Since babies born before 28 weeks’ gestation have a higher neonatal mortality rate than babies born later in pregnancy, additional babies born before 28 weeks’ gestation contributed to the overall increase in neonatal deaths in Scotland in 2021/22, the report found. This included a higher than expected number of multiple births such as twins and triplets.

There was a significant increase in the neonatal mortality rate for babies born at 32 to 36 weeks’ gestation in Scotland in 2021/22.

However, HIS said there were “no new or unusual causes of death identified”, and the registered causes of neonatal deaths in Scotland in 2021/22 were broadly similar to those in previous years.

Without comparative data from preceding years, the review’s authors said they could not determine if more than expected neonatal deaths in 2021/22 were “potentially preventable”.

From the information available in the local review reports, the review did not find evidence of systemic failures of maternity or neonatal care, either across Scotland as a whole, or in any one NHS board, that would account for the significant increase in neonatal deaths in 2021/22.

It also did not identify unusual factors or a cluster of any one factor to explain the increase in neonatal deaths in this period.

The report stated: “Whilst it is possible that the direct and indirect effects of the Covid-19 pandemic may have contributed, at least in part, to the increase in neonatal mortality in Scotland 2021/22, it is not possible to draw conclusions about this from the information available to this review.”

The review found variations in the quality and detail of local case reviews, as well as incomplete data around staffing levels during the pandemic.

Dr Mactier, an honorary senior research fellow at the University of Glasgow, said the death of a baby “is a devastating and traumatic experience for parents and families”.

“Although increasingly small and sick babies now survive, there will be some babies for whom this is not the case,” she said. “This does not necessarily reflect any shortcomings in care. However, it is important to acknowledge that some deaths may have been preventable.

“To prevent as many baby deaths as possible, review of both maternity and neonatal care is an essential part of midwifery, obstetric and neonatal practice. This review has helped to get a clearer understanding of the increase in neonatal deaths that occurred in 2021/22.

“We understand that there are still unanswered questions, and our recommendations are focused on ensuring that future opportunities to learn are not missed, and acted on in a timely and comprehensive manner.”

Public health and women’s health minister Jenni Minto said: “We welcome this report and accept the recommendations made. I’d like to thank the Healthcare Improvement Scotland team and expert group for their work. The review was commissioned so that we could better understand what may have caused the increase in neonatal mortality and to find ways that we can improve learning and future care.

“The findings made will now be considered carefully and we will work with Healthcare Improvement Scotland and other NHS partners on the next steps.

“We recognise the tragedy of losing a baby and the impact this report may have on grieving families and would encourage those who need additional support to get in touch with Sands’ or one of the other baby loss charities who provide bereavement support.”