Sands survey shows only a very small minority of parents were asked to participate in the review into their baby’s death

The Royal College of Obstetricians and Gynaecologists (RCOG) has reported on interim findings of its ‘Each Baby Counts’ project. It found that over a quarter (27%) of the investigations when things go wrong during labour were of poor quality.  

Additionally, in a quarter of cases, the parents were not made aware that an investigation was taking place. 47% of parents were made aware that an investigation was taking place and were informed of its outcomes, but only 28% of parents were invited to contribute to the investigation.

A separate survey conducted by Sands of nearly 300 bereaved parents of babies who died before during and after birth, has revealed that only 32% were told that the hospital was reviewing their baby’s death. Of those who were told about a review only 34% said they were invited to take part in it - 29 parents out of 287- and only around half report being satisfied with the process.

Judith Abela, Acting Chief Executive of Sands said: “These important findings add to the wealth of evidence that investigations into baby deaths are not of an acceptable standard.  A robust, thorough review process must be implemented without delay, and resourced adequately.

“Crucially, parents must be given the opportunity to input into the investigation into the death of their baby and the outcomes must be shared with them. Our recent survey confirms what parents have been telling us for many years, that they were neither informed nor consulted about the investigation, much less that they felt the process was adequate.

“We know that most parents would actively welcome the opportunity to be involved in the review of their baby’s death. Parents are the only ones there throughout the entire pregnancy and birth experience, at home, in primary care settings; in antenatal appointments and delivery units, and after the birth. They know how it was to be on receiving end of the care – what was positive about how they were treated, and what was not.

“It’s not about apportioning blame, rather ensuring everything possible is done to understand what happened so that we can learn from deaths and prevent future tragedies.”


1. For copies of the full Each Baby Counts report, please contact the RCOG press office on 020 7772 6444 or email

2. For further information and case studies please contact the Sands press office on 020 3598 1959 /