New data obtained by HSJ reveals babies are dying or being left with life-long disabilities because of mistakes being replicated across the NHS by midwives and doctors.
Clinical negligence claims broken down by primary cause of injury show a failure to properly monitor and respond to warning signs in babies’ heart rates, which is costing the NHS hundreds of millions of pounds a year.
The mistakes are not limited to a small number of cases – there are hundreds of claims a year, adding up to an almost £500m bill for the health service. This is despite multiple reports warning about the extent of the problem among midwives since 2009.
The issue relates to the ability of NHS staff to properly understand cardiotocograph, or CTG, readings. A CTG measures a baby’s heart rate and mother’s contractions.
Fears have been raised that some midwives lack key skills to interpret foetal heart rates and are not receiving adequate training to help them recognise when babies are at risk.
Experts have told HSJ trusts must invest in multidisciplinary training to improve workplace culture and enable staff to maintain competence throughout their careers. HSJ has identified one NHS trust that reduced its CTG errors to zero during the past 11 months after devoting more resources to the problem in the past year.
A national problem
Babies’ deaths and injuries as a result of staff failing to respond to abnormal foetal heart rates is a national problem that NHS trusts have been repeatedly warned about.
Data from NHS Resolution, formally the NHS Litigation Authority, shows there were almost 300 clinical negligence claims between 2011 and 2016 where the primary cause of the injury was a failure to respond to an abnormal foetal heart rate.
In 2015-16 there were 53 cases costing £214m. When failures to properly monitor stages of labour – which can include recognising and responding to deterioration in the baby or mother – are included there were 729 clinical negligence claims between 2011 and 2016.
In 2015-16 alone, the total cost of these cases was £467m. The NHS has been repeatedly warned over the dangers of CTG errors:
- A 2009 study of 100 stillbirth claims by the NHS Litigation Authority found “the most frequent example of negligence was in misinterpretation of CTG traces (34 per cent) with 25 cases identified as midwife error”.
- In 2012, the authority looked at a decade of maternity claims between 2000 and 2010, identifying 300 cases where abnormal CTG traces were not recognised or acted on. This study found midwives not seeking help when they should have done. It said 49 of the 50 midwifery related error claims needed obstetric assistance but help was only sought in 16 cases. In 33 claims, the midwife thought the CTG was normal when it was not.
- In one third of the CTG cases identified in the study, 117 babies suffered brain damage while 27, almost 10 per cent, resulted in the baby’s death. The report concluded: “The main concern with cases of CTG interpretation is the disproportionately high value of the claims”, and the total cost was £466m. The report urged trusts to invest in training, simulation, staffing levels and technology.
- In 2013, a study of perinatal mortality for NHS Cumbria looked at 60 deaths and concluded one of the common themes was “a failure to act on a suspicious CTG”.
- A report by the West Midlands Perinatal Institute in 2010 found 18 out of 25 baby deaths it examined involved a failure to recognise an abnormal CTG reading.
In recent months significant concerns have been raised by coroners about the standards of education and training for midwives after the deaths of babies who were starved of oxygen when warning signs were missed.
- Thomas Osbourne, senior coroner for Bedfordshire and Luton, wrote to Luton and Dunstable Hospital in January after baby Albie Marlowe was stillborn. Doctors went ahead with a normal delivery despite a “suspicious” CTG trace. Mr Osbourne said Albie’s mother had “begged” for a caesarean and expressed concerns that mothers at the trust were “not having their wishes respected and this is putting babies’ lives at risk”.
- In March, coroner David Hinchliff demanded changes to midwifery training after finding “significant failings” in the death of baby Billy Wilson who was born at Pinderfields Hospital in November 2013. His mother was given increasingly stronger medication to induce labour over six days despite the fact the CTG was warning Billy was suffering stress. A newly qualified midwife increased the dose on the night Billy was born despite a “pathological” change in the CTG. Once born he was rushed to Leeds General Infirmary but died three days later. The new midwife admitted at the inquest that she didn’t understand the CTG and claimed not to have been properly trained to interpret it at university. She had also yet to complete online training about CTG interpretation. Expert witness Professor Philip Steer, an obstetrician, said the problems were “commonplace and that student midwives can qualify and become registered without this essential training”.
- In February, Mr Hinchliff highlighted similar issues around the death of baby Maxim Karpovich, who died after an emergency caesarean in March 2015. He said: “It was apparent that the midwives involved with Maxim’s birth and the junior obstetrician appeared not to understand that the CTG trace was abnormal on several occasions… this inquest and many previously have caused me to note that midwives and obstetricians lack the core skills to interpret CTG tracings.”
- Health secretary Jeremy Hunt launched an investigation into babies’ deaths at Shrewsbury and Telford Hospitals Trust in April, with five out of an estimated 15 baby deaths linked to failures to monitor foetal heart rates.
Experts focus on teamwork
Eddie Morris, vice president for clinical quality at the Royal College of Obstetricians and Gynaecologists, said he accepted CTG mistakes were an issue for the NHS. He argued trusts need to focus on multidisciplinary training to reduce errors.
He said: “If we can get a team to function better then a lot of what we see in terms of CTG misinterpretations would be significantly reduced. It is about inter-professional trust and valuing other people. There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery.
“If you have a good working relationship between staff there is no doubt it is a good working environment and people will be more prepared to talk about things. It makes learning better.”
He said maternity departments should have regular simulations, drills and skills, and weekly CTG meetings where staff can discuss cases within a no blame culture.
Next month the RCOG will publish its Each Baby Counts report covering all 169 UK hospitals delivering babies. Mr Morris said the report will be “concentrating very hard on CTG interpretation and situational awareness as well as how the team functions”.
Mandy Forrester, head of quality and standards at the Royal College of Midwives, agreed teamwork was crucial but she warned that the NHS’s 3,500 midwives shortage meant some staff would be under significant pressure. She said: “If you are not able to provide one to one care there is more scope for error.”
She said RCM members had expressed concerns about outdated equipment and the increasing complexity of births. Ms Forrester added: “Trust leaders need to look at their maternity services, their outputs and statistics and reassure themselves that their trust is up to date with its training and to make sure that it is multidisciplinary. That is key. They should check processes that are in place are actually happening, that those are audited and that the audit loop is closed and evaluated.”
She also questioned the validity of the CTG as a tool but stressed that midwives must also refer concerns about a birth to doctors when issues beyond their scope of practice emerge.
Trust delivers major improvements
Barking, Havering and Redbridge University Hospitals Trust delivers more than 8,000 babies a year and has turned around its rate of CTG errors after investing in staff training, equipment and culture.
Wendy Matthews, director of midwifery at the trust, said 75 per cent of maternity incidents included some form of CTG error in 2015-16, but in the last 11 months the trust has not had a single CTG error.
Explaining how this had been achieved, she said: “We have put in place quite a rigorous process. We’ve developed a culture of quality and safety and learning from errors which is very much about the multidisciplinary team. I’m not sure how many trusts really do that.”
Changes the trust have implemented include:
- A dedicated CTG midwife to lead training for staff, including one to one.
- Central CTG monitoring and review by different staff every hour.
- An eight hour e-learning programme with staff given a day off to complete it. Doctors and midwives are not allowed on the labour ward until they complete the training.
- Weekly multidisciplinary CTG meetings for staff to discuss cases.
- Annual mandatory training on CTG that staff must pass.
- Replacing four different types of equipment with one single system.
- Multidisciplinary simulation training.
The Nursing and Midwifery Council said student midwives must be able to demonstrate they are competent to monitor mothers and babies during labour, but a spokeswoman added: “We recognise that concerns have been raised around the type and consistency of specific training in CTG tracing interpretation.
“We have recently commenced a wholesale review of our pre-registration midwifery standards and will be developing new standards of competence for future graduate registered midwives. As part of this review we will be carefully considering all the concerns that have been raised and will be looking at all available evidence, including the recommendations made by [David Hinchliff – see above], to ensure our standards are appropriate for future midwifery care.”
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.