Patient safety 'number one priority' says NHS trust following infant mortality report

Buckinghamshire Healthcare NHS Trust has said it ‘cares about people not statistics’ in response to an infant mortality rate report released last month which showed the Trust’s rate is over 5% above average.

The report by Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries (MBRRACE) revealed that in 2020 the Trust had an ‘adjusted’ perinatal mortality rate (still births and neonatal deaths) of 4.38 deaths per 1,000 births.

The average for its comparative group of over 4,000 births per year is 4.17 deaths per 1,000 births.

Buckinghamshire Healthcare NHS Trust stated that “the ratings on their own are not a measure of performance or safety” and that patient safety is its “number one priority.”

In total, the Trust experienced 22 deaths out of 4,622 births in 2020. Its perinatal mortality rate is below the UK average of 4.85 deaths per 1,000 births.

The full report can be found here.

The Buckinghamshire Healthcare NHS Trust statement reads:

"The Health Service Journal (HSJ), and subsequently the Daily Mail and the Daily Mirror, has run a story focusing on trusts that were ‘red rated’ by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) for perinatal mortality rates in 2020 (i.e. babies born after 24 weeks who die within 28 days of birth). Neither Buckinghamshire Healthcare NHS Trust (BHT) nor MBRRACE were approached for comment before publication.

"In 2020, Buckinghamshire Healthcare NHS Trust (BHT) helped to deliver 4,622 babies. Sadly 16 of these babies were stillbirths over 24 weeks and six died within 28 days of being born.

"As a Trust we care about people, not statistics, and the safety of all our patients and service users is our number one priority. We follow national guidance for internal reviews looking at each and every baby death to see if there is anything that we could have done differently that would have resulted in a different outcome. We also work closely with external agencies such as the Healthcare Safety Investigation Branch (HSIB) who independently review deaths when appropriate and we implement any recommendations they make as quickly as possible.

"All deaths are categorised by the Trust using MBRRACE gradings of care which determines if the death was avoidable or not. Of the 22 deaths reported by MBRRACE in 2020, two were graded by the Trust as having care issues identified that may have made a difference to the outcome – one of these was investigated by the HSIB and the coroner’s office with no recommendations made to the Trust and the other was the subject of an internal Serious Incident Investigation which made two recommendations that have been fully implemented by the Trust.

"The MBRRACE data is a useful guide for our maternity teams to identify areas for potential improvement but when looking at the figures, it is important to bear in mind the following:

"The ratings on their own are not a measure of performance or safety as there is no differentiation between avoidable and unavoidable deaths.

"Due to the very small numbers involved, 5% higher than a similar trust may be the equivalent of one baby.

"Figures are based on place of birth not the place of death. For example, if a seriously ill baby is born at Stoke Mandeville but is then transferred to another hospital for specialist care and subsequently dies, the death will be included in BHT’s figures not the hospital where the baby died.

"The loss of any baby is one too many. BHT is committed to ensuring that parents-to-be can expect the highest levels of safety when they choose to have their baby with us. We are committed to undertaking thorough patient safety investigations and ensuring that there is diligent external scrutiny of cases as part of the recently established serious incident review group across Berkshire, Oxfordshire and Buckinghamshire, as well as working with the HSIB.

"We continue to ensure that all families have the opportunity to engage with the Trust, are able to have their questions answered during the investigation and that investigation findings are shared in an open, transparent manner. The HSIB has reported that BHT’s family engagement rate is 94% compared to the national average of 86%."