The recent report by NHS Resolution – Five years of cerebral palsy claims, makes for very concerning reading.
The report contains too much information for one blog so I am just focusing on the cause of the majority of cerebral palsy claims in this article – errors with CTG traces. Fifty cases were looked at in the report. These had been the subject of claims in the period 2012 -2016.
Errors with fetal heart rate monitoring
Errors in interpreting cardiotocograph (CTG) made up 32 of the 50 claims assessed (64%).
Assuming each claim to be valued at £20 million (using the newly announced discount rate of -0.75%) these errors represent damages claims of £640 million. The value of the claims represent 24 hour care, often by two carers for the lifetime of each claimant. In addition there will be claims for loss of earnings and accommodation.
What is a cardiotocograph (CTG)?
The CTG is a device used record the baby’s heartbeat during labour. CTG monitoring is routinely used in the NHS to assess if the baby is in distress during the labour period. If the CTG begins to show that the baby is in distress then NHS guidelines require the baby to be delivered as quickly as possible.
What were the errors with interpreting CTGs?
There were 32 claims (64% of all claims reviewed) that involved errors in fetal heart rate monitoring. 91% of those, (29 claims) involved a cardiotocograph (CTG).
Errors using CTGs
|CTG not started when should have been||8||27%|
|False reassurance with an uninterpretable trace||5||17%|
|Too slow to act once CTG identified as pathological||3||9%|
|Monitoring maternal HR||2||7%|
In these 29 claims, 24 had a root cause analysis report performed, of which 18 sought to attribute errors in CTG use as a root cause.
The report states“The root causes were often described as a problem with individuals’ due to a “deficiency in CTG interpretation” or that an individual had “not followed CTG guidelines”.”
It goes on to say that;
“However, on reviewing these claims in more detail there appear to be other organisational, systemic and cultural factors that were not mentioned as a root cause. An example, was a Serious Untoward Investigation for a preterm pregnancy which identified the root cause as the midwife misinterpreting the CTG and not escalating for an obstetric review. On reviewing the timeline, combined with the expert statements, it was notable that there were multiple missed opportunities and the root cause does not lie solely with the individual midwife. The CTG was abnormal for 3.5 hours and during this time there were no ‘fresh eyes’ assessments, an hourly review of the CTG by another midwife, despite this being the hospital policy, the labour ward coordinator was in the room twice but did not review the CTG and there was no obstetric review despite this being a high-risk pregnancy. Why these potential fail safes did not work was not stated in the investigation.”
So the report confirms that individuals are being blamed in the NHS internal reports somewhat unfairly. Invariably these reports are conducted by the NHS Trust that stands accused of negligent treatment.
Incredibly, only 4% of NHS trusts who investigated cerebral palsy negligence cases brought in external auditors.
96% of NHS Trusts reviewed their own systems and culture when being blamed for a claim worth up to £20 million.
The report shows that when the alleged negligent NHS Trust investigates itself it seems that there is a high likelihood of that the blame will be put onto one person.
The upper echelons of that NHS Trust can then reassure themselves that no cultural or organisational change is required.
The stage is set for a repetition of that incident to occur. And again, no doubt, the next Serious Untoward Incident report will find that the subsequent incident was again due to individual error. And so the cycle continues.
Timing of cerebral palsy claims
Another feature of the report is to confirm what many claimant lawyers have always felt was the case – a disproportionate number of claims occurred at the weekend. Again, this is very concerning data for patients who are admitted to labour wards at the weekend.
|Time of Delivery||Number of claims|
|Monday to Friday 08:00-20:00||36%|
|Outside Monday to Friday 08:00-20:00||64%|
This is a very enlightening but concerning report which has been produced by Michael Magro for NHS Resolution.
This long overdue analysis I hope can now be used by the NHS as a springboard to improve patient safety. They clearly know where the risks in the system are and I hope that this report acts as a catalyst to ensure that resources are now targeted effectively.
I believe this report requires close attention so, I will be writing further blogs dealing with other aspects covered in the report.