A report entitled ‘Five years of cerebral palsy claims’ has been published by NHS Resolution. Its focus is on two important areas for improving practice:
- training to prevent future incidents and
- the quality of serious incident investigations
The report follows an in-depth review of claims arising from 50 births between 2012 and 2016. In each case, the child developed cerebral palsy allegedly resulting from negligent care.
As the author, Dr Michael Magro (NHS Resolution’s Darzi Fellow) points out, ‘These incidents are very rare however every case presents an opportunity for learning in order to improve the safety of maternity care.’
The study found that the most common theme was errors in fetal heart rate monitoring and that the causes were often not related to individual misinterpretation but to systemic or wider human factors. It also identified inadequate staff training and monitoring of competency as an important issue. Shortcomings in obtaining informed consent were apparent. Also, serious incident investigations were generally poor.
According to the report, the evidence suggests that unfortunately there has been little improvement in those areas in recent years.
Its main recommendations are as follows:
- Patients and their families should be asked to be actively involved in serious incident investigations
- The quality of serious incident investigations must be improved
- There should be independent peer review of all cases of potential severe brain injury, stillbirth or early neonatal death
- Support for staff following adverse events should be improved
- All staff should receive annual, locally-led, multi-professional training with focus on integrating clinical skills with enhancing leadership, teamwork, awareness of human factors and communication
- CTG interpretation should occur as part of a holistic assessment of fetal and maternal wellbeing
- The effectiveness of training should be linked to clinical outcomes
Clearly it is to be hoped that implementation of these recommendations will result in improvements in practice and increased patient safety. View the report.