Almost two thirds of clinical negligence claims involving maternity services included mistakes in monitoring baby’s heartbeats, a study has found.
NHS Resolution, formerly the NHS Litigation Authority, has published a new study of 50 maternity negligence claims where a baby suffered cerebral palsy between 2012 and 2016.
It found 64 per cent of cases included concerns over foetal heart rate monitoring, which was the most common issue. NHSR said it also identified systemic and human factors as the main causes of mistakes.
Only 40 per cent of families were involved in investigations into mistakes with the quality of root cause analysis “generally poor and focused too heavily on individuals”. NHSR warned that because of the poor quality investigations, “the recommendations were unlikely to reduce the incidence of future harm.”
Earlier this year, an HSJ investigation found that there were hundreds of negligence claims a year linked to the failure to respond to abnormal foetal heart rates adding up to an almost £500m bill for the NHS. Coroners have repeatedly raised concerns that midwives lack the skills to interpret heart monitoring cardiotocograph readings.
NHSR examined the data on negligence claims it held. Obstetric claims accounted for 10 per cent of the 10,686 claims received under NHSR indemnity schemes in 2016-17 but 50 per cent of the value, due to the life long care needs of children left disabled by mistakes made during their birth.
The report recommended that trust boards, alongside obstetric and midwifery leaders, ensure all staff undergo annual multiprofessional training, including simulation training for breech birth. This training should focus on integrating clinical skills with enhancing leadership, teamwork, awareness of human factors and communication. NHSR also said that the interpretation of foetal heartbeat should not occur in isolation.
Michael Magro, author of the report said: “Foetal monitoring is but a component part of a wider assessment of foetal 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.”
He added: “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 10 cases we found 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 10 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.”
Helen Vernon, chief executive of NHSR, said: “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.”
In November 2015, the Department of Health announced plans to reduce the rate of stillbirths, neonatal and maternal deaths in England by 50 per cent by 2030.