NHS Resolution report highlights failures in fetal monitoring as main contributor to brain injury at birth

A new report published by NHS Resolution at the end of September has provided an analysis of maternity cases passed through the organisation’s new Early notification scheme within the first year of its launch (2017/18).

Early Notification scheme

The Early Notification scheme is an initiative with the aim of ‘supporting both staff and families through a requirement for early reporting (within 30 days) to NHS Resolution of all term babies diagnosed with a potentially severe brain injury in their first week of life’.

The scheme has been designed to speed up identification of clinical negligence cases, and in turn, speed up admission of liability; the provision of necessary support and openness to families, as well as time-limiting the stress of investigations for professionals involved in such cases. By reducing the need for formal court proceedings and increasing the opportunity to learn from mistakes made, the scheme also has the potential to reduce NHS litigation costs.

Report findings

A sample of 96 of the 197 clinical negligence cases in which NHS Resolution panel solicitors where instructed was analysed. The report found that the most common contributing factor in all cases (70%) was staff failing to act on abnormal cardiotocographs (CTGs – a tool to assess the baby’s well-being during labour).

According to the report, admissions of liability were provided to 24 families of brain injured infants and all were within 18 months of the birth. The families in question were given an apology, a detailed explanation of how the brain injury was sustained, independent representation and financial assistance for immediate access to clinical, respite and psychological support.

Other issues identified within the report from NHS Resolution were as follows:

• Limited support to staff, confusion over duty of candour and insufficient family involvement
• In 63% of cases, at least two or more contributing factors were identified
• Concurrent maternal medical emergencies in labour occurred in 6% of the sampled cases
• Immediate neonatal care and resuscitation continues to be a an important but under-recognised factor towards newborn brain injuries, affecting 32% of the sample
• In 9% of cases, impacted fetal head and/or difficult delivery of the head during a caesarean section – a significant amount for an issue that has not previously been flagged by NHS Resolution

NHS England has recommended effective fetal monitoring, including CTG interpretation, during labour as a key component of care designed to reduce outcomes such as still birth. Furthermore, fetal monitoring leaders have been recommended in each trust and will be responsible for improving standards of fetal monitoring through various means, including multi-professional annual training for the relevant staff.

What more can be done?

However, despite training in this area being made mandatory in most trusts and with regular recommendations on the subject, mistakes continue to be made when it comes to fetal monitoring. But why? And what can be done to improve the current situation?

According to the mother and baby charity, Baby Lifeline, there are three major factors contributing to this: interpretation; culture; and training.

Interpretation

In a total of 43% of cases analysed, incorrect classification was identified. Wide variances to guidelines and types of language are used to assess, escalate and manage the results of fetal monitoring.

The charity says that instead, an agreed language and method should be used within all trusts. This should be based on hard evidence and should incorporate the ‘wider clinical picture for both mother and baby’.

Culture

In over half of cases studied in the report, there was a delay in acting on a pathological trace or abnormal heart rate and in 43% there was a delay in escalation.

Decision making and communication therefore need to be improved, say Baby Lifeline, with shared language and knowledge encouraged nationally for better and more-timely communication between staff.

Training

According to Baby Lifeline’s report in 2018, Mind the Gap, almost all trusts (99%) provided training in CTG/electronic fetal monitoring and the training was found to be compulsory for at least one staff group within those trusts. The issue lies with the differences in terms of the contents of the training, as well as differences between how each trust measures attendance, assessment and the handling of administration.

To tackle the above, Baby Lifeline are working with leading experts and organisations to develop evidence-based training programs to help ‘frontline maternity professionals to deliver safe maternity care and reduce avoidable harm’. More information on Baby Lifeline’s training can be found via their website.

Gill Edwards is a Partner within our Clinical Negligence department who specialises in acting on behalf of newborns and children who have suffered brain injury at the time of their birth. Gill is also a member of Baby Lifeline's Multi-Professional Advisory Panel, she comments here:

It is frustrating that the same errors are seen repeatedly and failures in the interpretation of CTG traces has been an ongoing issue for many years with a devastating impact on babies and families. Baby Lifeline points out that training is important but also a cultural change is needed. The Early Notification Scheme is pulling the data together and I hope with time that improvements in outcomes will be seen.

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