Brain damage risk for babies ‘still a concern’
Rates barely change after 20 years
BABIES ARE just as likely to be left brain-damaged by the most serious errors in maternity care as they were 20 years ago, a new report says.
A review of NHS compensation claims found that the most serious examples of medical negligence – including failure to monitor heart rates properly – have barely changed in the last 20 to 25 years.
The report points to issues with individual midwives and doctors but also says there are NHS-wide problem with staff training.
It gives examples where medics have attempted to deliver breech babies despite having no experience or training, midwives were left to monitor heart rates despite not fully understanding them and one doctor did not know how to resuscitate a baby.
The report, from NHS Resolution, which handles NHS compensation claims, is intended to help improve learning across the NHS to ensure mistakes are not repeated.
Experts looked in detail at 50 cases from 40 NHS trusts where a child suffered cerebral palsy due to medical errors, and where the NHS has admitted liability.
All the cases occurred between 2012 and 2016 and were taken from a total of 296 compensation claims for cerebral palsy made by affected families.
The analysis showed that the investigations carried out by NHS hospitals when things go wrong are “poor” quality and six in 10 do not involve parents.
Internal investigations were also quick to explain what had happened but failed to fully explore why in order to prevent mistakes being made again.
Out of 50 reports, 26 commented on the poor skill level of staff involved, while 22 cited poor communication on wards, 18 said guidelines or policies were not followed and 17 said individual members of staff had inadequate knowledge.
Some 10 cases involved issues with equipment, seven pointed to too few staff being on duty and four mentioned excessive workloads as contributing to delivery of brain-damaged babies.
There were problems with neonatal resuscitation in nine cases, with two cases where midwives or doctors did not ask for help from more senior staff.
Meanwhile, six cases involved breech babies and staff struggling to deliver them.
Overall, obstetric claims accounted for 10 per cent of the 10,686 claims received under NHS Resolution’s indemnity schemes in 2016/17. The NHS compensation bill in 2016/17 was £1.7bn.
Author of the report, Dr Michael Magro, said: “These incidents are very rare, however every case presents an opportunity for learning in order to improve the safety of maternity care.”
Professor Zarko Alfirevic, colead investigator on the Royal College of Obstetricians and Gynaecologists Each Baby Counts programme, welcomed the study, adding: “The emotional cost to each family is incalculable and we owe it to them to properly investigate what happened.”
Every case presents an opportunity to improve safety of care. Dr Michael Magro, author of the report on NHS obstetric negligence claims.