It is with a heavy heart that I type this blog.
I have just read through the recently published report entitled ‘Five years of cerebral palsy claims’ by NHS Resolution, the body that handles NHS compensation claims. In short, the report shows that the most serious errors in maternity care have not changed in the last 20 to 25 years.
The report, which looked at 50 cases from 40 NHS Trusts in which the NHS had admitted liability for medical errors resulting in a child suffering cerebral palsy, states:
“The evidence suggests that very little, if anything, has changed over the last 20 to 25 years.
“A 1991 review of 110 cerebral palsy compensation claims identified that 70% were related to CTG abnormalities and CTG interpretation, while a 2004 review of medicolegal aspects with cardiotocography identified identical themes to this review - recording of maternal pulse, poor quality erratic tracing, misinterpretation, inaction with suspicious or abnormal CTGs and failure to incorporate the clinical picture.”
How, in a quarter of a century, can identifiable areas of negligence in maternity care still remain unaddressed? Why aren’t lessons being learned?
Time and time again I, as a clinical negligence lawyer, see the same mistakes being made and the devastating results for the children and families affected: errors in fetal heart rate monitoring and its interpretation, mismanaged instrumental delivery, inadequate training of medical staff to name but a few.
It is also frustrating to see in the report that six in 10 internal NHS investigations do not involve the parents. At a time when parents are desperate for answers in relation to what went wrong and what will happen now, they are excluded from key discussions. In fact, I have lost count of the number of the times parents have told me they think they would never have found out what went wrong with the delivery of their child if it had not been for the legal investigation. Openness and transparency with parents affected by birth injuries is sadly, in my experience, hugely lacking.
Those children and families affected by errors in medical care are entitled to be included, as little or as much as they choose, in a thorough investigation that sets out what happened, what went wrong and what lessons will be learned.
Dr Michael Magro, the report’s author, said: “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 reports 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.”
The report says that while internal investigations by Trusts set out what happened, they fail to look at why these events happened and as a result, lose the opportunity to learn from their failings.
The same mistakes in maternity care simply cannot continue to be made without lessons being learned. It is all well and good for Trusts to take the time to investigate when failings have occurred, but without taking the steps needed to ensure errors are acknowledged and changes are made, how are other children and families protected from suffering the same tragic consequences?
While the report details issues with individual midwives and doctors, it highlights the much bigger issue of inadequate staff training. Tied in with this is the Royal College of Midwives data which says England is 3,500 midwives short of the number it needs.
It is stated that the purpose of the report is to help improve learning across the NHS to ensure mistakes are not repeated. Now is the time for action. Now is the time for change. NHS Trusts should not let another quarter of a century pass and miss the opportunity to learn from the continued and publicised failings in maternity care. These continued errors should and can be avoided.