Babies' deaths linked to suboptimal care

BMJ 1995; 310 doi: (Published 25 March 1995) Cite this as: BMJ 1995;310:757

Over 40% of the deaths in healthy babies in Britain that occur during birth are linked to suboptimal care, said a government report last week. The first investigation into the deaths of 388 babies by the confidential inquiry into stillbirths and deaths in infancy found that the main failures were “human beings and the particular circumstances in which they found themselves.” The report states, “This human factor included insufficient skills, inappropriate attitudes and apparent lack of senior accountability.”

Failure to react to abnormal cardiotocographs was the commonest reported problem, although induction procedures were criticised for lack of senior supervision, inadequate monitoring, and overdosage with prostaglandins or oxytocin. In 43 of the cases poor resuscitation technique contributed to the baby's death. In one case a junior paediatrician tried to intubate a baby four times. “This removed any chance the baby might have had,” said the report.

The inquiry was set …

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