‘Lack of curiosity’ contributed to stillbirths, review finds

An area with high stillbirth rates has found there were “significant” gaps in maternity care in more than one in five cases, in a newly published review.

The review of stillbirths across the Black Country was commissioned by its local maternity and neonatal system (LMNS), following an increase in rates since 2020. 

The review, dated March 2024, has just been published by the integrated care board, after repeated requests from HSJ  and others.

It states that stillbirths and neonatal deaths were both continuing to increase in 2023, but “this is at a more significant rate for stillbirths”.

More than a fifth (22.5%) of the reviews identified “significant modifiable factors” – where different management might have saved the baby’s life – and 42.5% found “minor modifiable factors”, which are issues that may have contributed but are unlikely to have changed the outcome.

The review, carried out by a panel of senior local clinicians, sets out a wide range of shortcomings in the cases, and recommendations.

It gives several examples where there is a failure to pursue apparent concerns and warning signs during pregnancy.

Under issues with “risk assessment”, the report says: “There was a concern that there appeared to be a lack of professional curiosity. Particularly in relation to medical problems that occurred during the pregnancy and the discord between the plans for pregnancy care and the implications of the medical problems and their effect on the pregnancy and care.”

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Source: HSJ, 25 September 2025