HSIB National Learning Report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia (4 February 2021)

Summary

In March 2020, the Healthcare Safety Investigation Branch (HSIB) published a national learning report to highlight the themes emerging from the initial investigations carried out as part of their maternity investigation programme. These initial investigations were carried out between April 2018 and December 2019.

One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia).

This was identified as an area where further analysis could benefit system-wide learning.

Content

HSIB's national learning reports can be used by healthcare leaders, policymakers, and the public to:

• Aid their knowledge of systemic patient safety risks.
• Understand the underlying contributing factors.
• Inform decision making to improve patient safety.