Inadequate maternity care potentially caused the death of 21 babies during labour and childbirth in the West Midlands, according to the findings of an independent enquiry.

The enquiry, which was commissioned by NHS West Midlands, looked at baby deaths during labour and childbirth between April 1, 2008 and March 31, 2009.

After excluding congenital cases, all stillbirth were included and premature births before 34 weeks – there was a total of 25 unexplained baby deaths during labour and childbirth in this period.

The figure is a fraction of the total number of babies born in the West Midlands - less than 0.1 percent of the 71,000 new births.

However, the findings of the Confidential Enquiry into Intrapartum Related Deaths are hugely disappointing for health chiefs who had hoped that the number of such deaths had fallen during the course of the last decade.

Fay Baillie, Clinical Lead for Maternity and Newborn at NHS West Midlands, said: “The report is really disappointing. It has identified that there have been babies that have died in the West Midlands for whom we as health professionals could have provided better treatment.

“It is not something that we should underestimate in terms of an emotional response to it and it is something we must improve upon.

“This is an awful report for anyone who works in maternity care, but while these conclusions may be hard to swallow it is vital that the NHS continually questions itself by commissioning such enquiries in order to try and improve care in the future and prevent such tragic deaths from happening.”

Janet Scott, from the charity Sands, which represents stillbirth and neonatal death, said she was shocked by the report’s findings.

She said: “If 21 children died in the West Midlands due to poor care there would be an outcry, so why are the deaths of 21 babies going seemingly unnoticed?

“Depressingly the same poor levels of care have been identified in previous national reports over the last ten years. Why aren’t lessons being learnt and babies’ lives being saved?”

The baby death cases investigated were drawn from 15 out of the West Midlands' 16 hospital trusts.

A panel made up of senior midwives, obstetricians and other maternity experts found examples of substandard care in each of the 25 baby deaths it reviewed.

In 21 of the cases the panel concluded that different care ‘might have made a difference to the outcome’.

In 16 of the cases it concluded that different care would have ‘reasonably been expected to have made a difference to the outcome’.

It is therefore reasonable to conclude that 16 babies died in labour or childbirth because they received inadequate care.

The review identified failings in various stages of the pregancy, labour and childbirth process.

It found seven cases where risk factors were missed during pregnancy and where poor management plans were implemented.

In 16 cases staff failed to interpret heart readings correctly and consequently did not identify potential problems in labour.

Delays in delivering babies were highlighted as potential causes of death in 12 of the cases.

In 18 cases the panel felt staff had failed to escalate a serious problem which required senior input or assistance.

Seven of the nine cases in which babies died soon after they were born, the review panel found that inadequate resuscitation efforts were made.

This was also found in 10 of the stillbirth cases that the panel looked at. After a mother lost a baby substandard support and bereavement care was received in seven of the cases.

The enquiry was carried out by West Midlands Perinatal Institute.

Conclusions about levels of substandard care were reached by consensus among panel members.

Substandard care potentially leading to the death of babies was identified nationally as far back as the early 1990s and a number of reports published since then have raised similar concerns.

The report, which was conducted by the West Midlands Perinatal Institute for maternal and child health, found wide variation in the way the cases were reviewed by trusts.

It found that as many as three quarters of the concerns raised by the enquiry review had not been picked up by in house trust reviews.

Report author professor Jason Gardosi, from the West Midlands Perinatal Institute, said previous enquiries did not reduce childbirth baby death rates because they did not identify quality and consistency failings of internal reviews.

Due for review December 2011