NHS study of cerebral palsy facts reveals systemic and human errors
Analysing five years of NHS data on cerebral palsy claims, it acknowledges that systemic and human errors in monitoring fetal heart rate remain the most common cause of babies born with cerebral palsy, which is clearly and consistently down to inadequate training and lack of competency – a fundamental failing that we have written about previously.
The report also highlights the handling of breech birth as a concern, the way investigations into avoidable errors are handled and the poor quality of root cause analysis. Particularly worrying here is that only 4 per cent of such investigations involve an external reviewer and that less than half involve the patient and family. Poor quality reporting means recommendations are unlikely to reduce future harm – which is the whole point of investigations.
While the NHS remains the safest healthcare system out of 11 western countries, it's a sad truth that negligence resulting in babies born with cerebral palsy generates the most expensive, and most devastating, claims against the health service.
The number of such claims for cerebral palsy and neonatal brain damage has remained roughly static over more than 10 years – 247 in 2004/5, 232 in 2016/17 - raising the obvious question why have so few lessons been learnt and acted upon over such a long time?
NHS Resolution, when it reinvented itself from NHSLA earlier this year, stated its focus will be on learning from what goes wrong to make the right changes to prevent harm occurring in the first place. This latest report is part of an urgent and wider government investigation into maternity services, recommendations from this year's Better Births campaign and an upcoming review of the way serious incident investigations are run.
While the facts reported in it are unsurprising, merely echoing its predecessors, let's hope it can surprise us by finally making sure that recommendations and potential solutions offered up time and again actually generate change, particularly around CTG monitoring, the basis of maternity care. Otherwise, NHS R runs the risk of yet another exercise in stating the obvious.
Summary of recommendations from '5 years of cerebral palsy claims' report:
- Cardiotocograph (CTG) interpretation should not occur in isolation but as part of holistic assessment of fetal and maternal wellbeing. CTG training should incorporate risk stratification, timely escalation of concerns and the detection and treatment of the deteriorating mother and baby.
- Women and their families offer invaluable insight into the care they received. SIs (Serious Incidents) should not be ‘closed’ unless the woman and her family have been actively involved in the investigation process.
- To improve the quality of those reports, there should be discussion around creating a national standard and accredited training for staff conducting investigations.
- All cases of potential severe brain injury, intrapartum stillbirth and early neonatal death should be subject to an external or independent peer review.
Trust boards, with their obstetric and midwifery leads, must ensure that all staff undergo annual, locally led, multi-professional training, which includes simulation training for breech birth. Staff should not provide unsupervised care on delivery suite until the competencies have been achieved.
Trusts should monitor the effectiveness of their training by linking it to clinical outcomes. Trust boards should encourage units to publish their local indicators, which can then be subject to benchmarking and external scrutiny.