A father whose twin baby died just an hour after birth following a botched caesarean section has called on hospitals to learn from their experience.
It comes as the Royal College of Obstetricians and Gynaecologists (RCOG) has released a report on cases of stillbirth, early neonatal death and severe brain injury caused during labour, many of which were preventable.
The case of baby Thor Dalhaug and the subsequent investigation into the cause of his death is one of hundreds of case studies included in the Each Baby Counts report published on Thursday, which concluded that ‘more robust and comprehensive local reviews are urgently needed to ensure lessons can be learnt and improvements made’.
Thor died in September 2013 after a surgeon at Lincoln County Hospital used delivery methods later described by a coroner as ‘unorthodox and unacceptable’. This included the use of forceps by the surgeon – on her first day at the hospital – which led to Thor suffering a major brain haemorrhage.
Following an inquest, coroner Stuart Fisher accused senior management at the United Lincolnshire Hospitals NHS Trust of attempting to cover up circumstances which led to Thor’s death, including the use of forceps.
It was a horrific experience for parents Rolf and Michelle Dalhaug, who live in Grantham with their son Harrison, who was born healthy shortly after Thor.
Keen to help avoid other parents going through the same ordeal, they contributed their story to the RCOG initiative. It aims to halve the number of deaths during labour nationally by 2020.
Mr Dalhaug, 40, said: “Thor’s death highlights the importance of continued learning and review of all neonatal deaths, and the RCOG Each Baby Counts project is critical to this.
“The loss of Thor has devastated our lives, and we count ourselves amongst the lucky ones as we still have Harrison – we live for him.
“Every day, every birthday, every Christmas, every first has been a great joy tainted by deep sadness. We will carry the scars of Thor’s loss and the circumstances of his death for the rest of our lives.”
Each Baby Counts is a national quality improvement programme which launched in October 2014.
So far, 921 babies have been reported to the programme. Of these, 654 were classified as having severe brain injuries, and there were 147 early neonatal deaths and 119 stillbirths that occurred during term labour.
Of the 610 reports which have been completed, 599 (98 per cent) have had a local investigation of some kind. Further data shows that many investigations carried out were done so poorly and often ended with no action taken to improve care.
Professor Alan Cameron, RCOG vice-president for clinical quality and co-principal investigator for Each Baby Counts, said: “Currently, there is a lack of consistency in the way local investigations are conducted. When the outcome for parents is the devastating loss of a baby, or a baby born with a severe brain injury, there can be little justification for poor quality reviews. Only by ensuring that local investigations are conducted thoroughly with parental and external input, can we identify where systems need to be improved. Once every baby affected has their care reviewed robustly we can begin to understand the causes of these tragedies.”
“Learning is important, but decisive action from this learning is vital,” urged Mr Dalhaug. “Trusts, boards and senior management must understand that their roles, their governance and the standards they set are just as critical to life-saving care as the medical professionals on the ground. They have an equal duty to the people they serve to do everything in their power to save lives and they must make a personal investment in this – this is their duty.
“Complacency is not an option. Complacency is costing hundreds, if not thousands of innocent lives. This is not acceptable.”