NHS resolution, the body which represents NHS Trusts in clinical negligence claims, has produced a significant report analysing 5 years of Cerebral Palsy claims involving injuries at birth.
Cerebral Palsy is caused by the deprivation of oxygen to the brain during the latter stages of delivery and often causing catastrophic injury to the baby, resulting in life changing circumstances to both the baby and their family. In England, for every 1,000 births, approximately 2 result in Cerebral Palsy.
The NHS Resolution report, published in September 2017, had 3 key aims:-
To identify the clinical and non-clinical themes from Cerebral Palsy claims resulting in a claim for compensation;
- Disseminate the shared learning and to use this as a driver for change and quality improvement;
Highlight area for improvement and evidence of good practice, sign post potential solutions and make recommendations for change.
The report identified that the cost of litigation, including damages, where the trust was responsible for the Cerebral Palsy and condition to the child, amounted to £1.7 billion in 2016/17. Obstetric claims accounted for 50% of the total amount of claims settled by the trust in 2016/17.
It was found that there were still substantial errors and learning was needed within the NHS. Amongst the concerns, the report identifies:-
A lack of family involvement and staff support through the investigation process;
The quality of root cause analysis was generally poor and focused too heavily on individuals
Due to the poor report quality, the recommendations were unlikely to reduce the incidence of future harm
The second part of the review identified issues with the following:-
- Foetal heart rate monitoring;
- Breach birth;
- Staff competency and training;
- Patient autonomy.
Amongst the significant key findings and failures, the report identified:-
Poor evidence of serious incident investigations at local levels;
The patient and family were only involved in 40% of investigations;
Only 32% of investigations had a review that had involved an obstetrician, midwife, and neonatologist;
Only 4% of investigations had an external review;
Reports were too heavily focused on individual errors rather than systematic errors;
Errors with foetal heart rate monitoring were the most common theme;
Breach births were over represented within the review and in comparison to the national average;
Inadequate staff training and monitoring of competency identified a significant failing;
There were short comings in informed consent.
The 50 or so claims, which were analysed as part of the review, all had liability admitted. They all related to two children born with CP or brain injury, who otherwise, tragically, would have been born without a long term disability had it not been for the medical error or negligence. The report identifies, that the largest amount of errors involved foetal heart rate monitoring amongst the lead causes identified, amounting to 64% of total. Of the claims identified, cut errors using CTG’s were as follows:-
- CTG’s misinterpreted (11 cases);
- CTG not starting when they should have been (8 cases);
- False reassurance with uninterpretable trace;
- Too slow to act upon CTG identified as pathological;
- Monitoring of maternal heart rate.
- Significant numbers of these errors were performed by midwives rather than consultants.
Of those the case reviewed, 58% involved the need for extra staff training to be implemented. Significantly, the report identified, a high portion of cases did not involve full family involvement when, clearly, the effects of having a child with Cerebral Palsy are substantial.
The report concluded 7 recommendations:-
Women and their families offer invaluable insight into the care they have received and should be actively involved throughout the investigation process;
The quality of serious investigations has repeatedly been found to be poor. Consequently, there is a suggestion that a working party possibly led by the Health Care Safety Investigation board should discuss creating a national, standardised training programme for all staff conducting investigations;
Significantly, in line with the Royal College of Obstetricians and Gynaecologists “Each Baby Counts” report, every case of severe brain injury, intrapartum still birth and neonatal death should be subject to external independent peer review
Adverse events within maternity units have serious negative impacts on staff and improving emotional support for staff throughout the investigation should be a priority;
The level of training to midwives should be more focused and regular;
CTG interpretation (foetal heart rate monitoring) should not occur in isolation;
Trust should monitor the effectiveness of their training by linking it to clinical outcomes.
In my opinion, the report provides an invaluable insight in to the causes of Cerebral Palsy and the key factors which contribute to negligence within the maternity units. I welcome the report in terms of identifying the causes of avoidable injury and the recommendations, but without implementation of the recommendations, the errors and problems identified will continue.
From my experience, the lack of CTG interpretation and training of midwives dealing the emergency situations is having a significant impact. The cost to a family is not only littered with regret, but often parents feel somehow they could have prevented the injury. This is almost inevitably not the case. What worries me about the report is it is reliant on cases put forward by the NHS’s own solicitors. The report only addresses those cases in which admissions of liability are made. There are of course a significant number of cases in which the Trust will deny liability but ultimately either are found culpable or settle the claim. Arguably, the report is flawed as it is not based on all successful Cerebral Palsy cases.
Until there is more investment within Maternity Services, in terms of training and additional midwives, sadly, these errors or mistakes will continue to be made.
Farleys currently act for a number of families who have lost children either through still birth or neonatal deaths and who have suffered brain injury. If, you have been affected by the issues arising in this article, please contact our specialist solicitors on 0845 287 0939 or email us.