NHS Resolution’s review of five years of cerebral palsy claims is a vital step towards preventing future harm
A new report from NHS Resolution, ‘Five years of cerebral palsy claims’, provides an in-depth examination of the causes of these rare but tragic incidents and the investigations that follow them. Working in partnership with other organisations, including The Royal College of Obstetricians and Gynaecologists, The Royal College of Midwives, NHS England and NHS Improvement, NHS Resolution highlights areas for improvement and makes clear recommendations to help trusts prevent further incidents.
The study draws upon the unique dataset held by NHS Resolution to focus on two key areas for improvement; training to prevent future incidents and the quality of serious incident investigations.
These incidents are very rare however every case presents an opportunity for learning in order to improve the safety of maternity care. In six out of ten cases we found that women and their families were not being involved in investigations. Where families can, and are willing to participate in investigations, they bring a unique perspective and invaluable insight as to what went wrong. We recommend that serious incident investigations should not be closed unless the family have been actively involved throughout the investigation process or else have explicitly confirmed that they do not wish to be involved. We also found that in four out of ten cases staff were not offered support. Just as families and carers need help, we also have a duty to support NHS staff. These cases are tragic and can be traumatic for all those involved.
Dr Michael Magro, NHS Resolution’s Darzi Fellow and author of the report
Obstetric claims accounted for 10% of the 10,686 claims received under NHS Resolution’s indemnity schemes in 2016/17 but 50% of the value due to the devastating nature of the injury and the often life-long care needs of the child.
The report focuses on 50 cases of cerebral palsy where a legal liability has been established. Echoing a similar study in 2012, errors in fetal heart monitoring are found to be the most common clinical theme. However, although investigations often focus on individual errors, it is found that underlying causes are more often systemic, multifactorial and relate to wider human factors. Other findings include the high proportion of breech deliveries within the cohort, improvements needed to the governance surrounding multi-professional training and inadequate informed consent.
The report recommends that trust boards, alongside their obstetric and midwifery leads, ensure that all staff undergo annual, locally led, multi-professional training, which includes simulation training for breech birth. This training should focus on integrating clinical skills with enhancing leadership, teamwork, awareness of human factors and communication. NHS Resolution also recommends that the interpretation of fetal heartbeat should not occur in isolation.
Fetal monitoring is but a component part of a wider assessment of fetal and maternal wellbeing. As such, training should include risk stratification, the timely escalation of concerns and the detection and treatment of the deteriorating mother and baby.
Dr Magro
Negligent care resulting in cerebral palsy has a devastating and lifelong effect on the child, their family and carers. Whilst thankfully, these cases are very rare, they can be prevented. What we have learned from these events and the steps that we and our partners have committed to as a result, represents a vital step towards preventing future harm.
Helen Vernon, Chief Executive of NHS Resolution
We welcome this thorough report. The findings echo the recommendations of our latest Each Baby Counts report which aims to deliver improvements in maternity care and reduce the number of babies who die or are left severely disabled as a result of avoidable incidents occurring during term labour. The emotional cost to each family is incalculable and we owe it to them to properly investigate what happened and ensure the individuals and the healthcare Trusts involved take the steps needed to learn from these incidents and avoid these tragic incidents occurring again.
Professor Zarko Alfirevic, co-lead investigator on the Royal College of Obstetricians and Gynaecologists Each Baby Counts programme
