Cerebral palsy is a general term that is usually used to describe someone who suffers from a disorder of voluntary movement and coordination due to injury to the immature developing brain. It is estimated that 1 in 400 children in theUKis affected by cerebral palsy. It is a non-progressive condition, which means that it will not worsen with increasing age, and there are many adults who have cerebral palsy.
Types of cerebral palsy
There are primarily four different types of cerebral palsy:
- Spastic cerebral palsy, in which there is increased muscle tone (hypertonia) in the body and the muscles are tight, stiff (spastic) and weak. Spastic cerebral palsy is also often described as hemiplegic (affecting one half of the body, either left or right), diplegic (affecting primarily the legs) or, in its most severe form, quadriplegic (affecting all four limbs).
- Ataxic cerebral palsy, in which there are abnormal unwanted jerking and shaking movements, which disrupt movement control and which affect balance.
- Athetoid (dyskinetic or dystonic) cerebral palsy, where there are involuntary writhing movements that affect movement control, with increased or decreased muscle tone (hypotonia), which can fluctuate. Speech is often affected making communication difficult.
- Mixed cerebral palsy, which is a combination of two or more of the above.
Cerebral palsy is caused by brain injury that occurs before, during or after birth, and there are many causes of that brain injury, including infection during pregnancy, congenital abnormalities of the brain, genetic conditions, trauma and cerebral bleeding, low birth weight or premature birth.In clinical negligence, cerebral palsy often refers to brain injury caused by hypoxia (a lack of oxygen) during the delivery process (intrapartum asphyxia). Such cases only account for a very small number of overall causes of cerebral palsy, however (probably only up to about 5%). As a rule of thumb, the type of cerebral palsy can assist with explaining the underlying cause: a very severe but relatively short (as little as 10 to 20 minutes) period of hypoxia will tend to cause the athetoid form of cerebral palsy (as a consequence of damage to the most metabolically active part of the brain, called the basal ganglia, which are involved in involuntary movement control), whereas a less severe but prolonged (possibly over a number of hours) period of hypoxia will tend to cause the spastic quadriplegic form of cerebral palsy (as a consequence of damage to the cerebral hemispheres, which are involved in voluntary motor control and cognitive ability). In the clinical negligence context, there are a number of relatively common events that can result in cerebral palsy caused by clinical negligence during birth, and it is these (amongst others) that we look for during the investigation of such a case. These include:
- Failing to interpret properly the cardiotocograph trace (CTG), the baby’s heart monitor
- Failing to deliver quickly enough, especially if there has been a long, poorly progressing labour and/or a lengthy delivery
- Failing to act quickly enough when fetal distress is present
- A delay or failure in attendance by obstetric doctors, leaving a complicated delivery only to midwives (or the failure of the midwives to call for the doctors)
- A delay in performing an emergency caesarean section
- Failing to resuscitate appropriately after delivery
The features of cerebral palsy vary hugely from individual to individual, depending on the type of cerebral palsy, the underlying cause and the severity. In addition to the movement and coordination problems described above, cerebral palsy individuals can suffer with a number of other problems, including global intellectual impairment, learning difficulties, epilepsy, visual and hearing impairment, difficulty speaking and communicating, scoliosis (a curved spine, which can commonly occur with a hemiplegia) and drooling.
The diagnosis of cerebral palsy is primarily a clinical one, but investigations are undertaken to identify the underlying cause if possible. Blood tests are usually performed, as well as cranial ultrasounds, CT and MRI brain scans. In the context of investigating the possibility of clinical negligence in someone with cerebral palsy, probably the most important investigation, however, is the MRI brain scan, because it is important to try to identify what has caused the underlying brain injury. The medical experts required in a birth-related clinical negligence cerebral palsy case are most likely to be:
- Midwife, to comment on the standard of care of the midwifery staff involved in the labour and delivery
- Obstetrician, to comment on the standard of care of the obstetric medical staff
- Neuroradiologist, to interpret the MRI brain scan
- Neonatologist, to comment on the likely cause of the cerebral palsy and whether earlier delivery would have made any difference to the outcome
Sadly, there is no cure for cerebral palsy and it is a permanent condition. However, there are various ways that health professionals can assist a patient with cerebral palsy. Many of these types of professionals will also be involved as experts in the quantification of a successful cerebral palsy clinical negligence claim, including:
- Paediatric Neurologist or Developmental Paediatrician, to analyse the type of the cerebral palsy, to comment on prognosis (including estimated life expectancy) and on any medical intervention that may be of assistance, including such treatment as baclofen (to reduce stiffness), botulinum injections (to reduce contractures and drooling), melatonin (to aid sleep), diazepam (as a muscle relaxant), etc.
- Care expert, to advise on the required care and case management package
- Educational psychologist, to aid patients with learning difficulties and also to assist with any psychological difficulties that patients may have, such as anxiety and depression, which may require treatment, such as medication and/or cognitive behavioural therapy, etc.
- Occupational therapist (OT), to assist with activities of daily living, such as washing, dressing, etc.
- Physiotherapist (PT), to help improve a patient’s movement and coordination
- Speech and language therapist (SALT), to help with a patient’s ability to communicate
- Assistive technology expert, to advise on the aids and appliances available to help the patient interact with their environment, including eye-gaze technology, wheelchairs, computers, environmental controls, etc.
- Accommodation expert, to advise on the specialist housing requirements
- Orthopaedic surgeon, to advise on any procedures that may be required to assist with hip subluxation, scoliosis, contractures, etc.
- Gastroenterologist, especially if feeding is required by tube (percutaenous gastrostomy feeding, PEG).
Cerebral palsy claims are usually high in value, often totalling many millions of pounds, although most claims now are concluded in the form of a combination of annual periodical payments and a capital lump sum. Our team of specialist clinical negligence lawyers has particular expertise in cerebral palsy cases and has settled many such claims; my most recent settlement earlier this year exceeded £8 million.