Sometimes babies die because of failures of care. The recent MBRRACE-UK confidential enquiry into antepartum term stillbirths found that in six out of 10 cases, the stillbirth might have been avoided if health care professionals had cared for the mum and baby according to guidelines set out by NICE. Shockingly of all, in only 10% of the 133 cases of stillbirth in 2013, reviewed by the enquiry was a hospital-based review of care undertaken in line with standards set out by the Royal College of Obstetricians and Gynaecologists (RCOG).  

The recent Lancet Series: Ending Preventable Stillbirths reported that research shows a high proportion of stillbirths both globally and in high incomes countries like the UK, are avoidable. Yet lessons about what went wrong are too often overlooked and opportunities to improve care are missed. Sands believes every baby’s death from 22 weeks to 28 days of life should be reviewed in a robust and systematic way. Sands and the Department of Health have outlined those principles of review with a multi-disciplinary task and finish group, with broad representation from all stakeholders including parents, and developed an auditable set of data to assist in the review process. The DH is commissioning this work to transform it into web-based tool that can be used at unit level. 

For an update on this work, please email