A very concerning report published by NHS Resolution this month highlights that the inability of staff to respond to CTG monitoring during a mother's labour is the most common reason behind cases where babies are born brain damaged. The report also identified ongoing failures by hospital trusts to follow statutory duty of candour when dealing with the families of injured babies and to apologise for mistakes.
The report follows analysis of the early notification scheme, introduced by NHS Resolution a year ago, aimed at speeding up the time in which families receive an admission of liability where negligence is involved, a formal apology and financial compensation – all supposedly within 18 months.
We have discussed before our concerns that rushing through a claim in this way potentially undermines proper analysis and calculation of the ongoing needs of a brain injured child which, in our experience, can take years to properly assess. The advantage of course is that the scheme should reduce the legal costs for the NHS, which can only be a positive move, but the needs of the injured family must take priority.
In medical terms, the report reveals that 70 per cent of cases dealt with within the scheme involve fetal monitoring as a contributory facture, with delays in birth featuring in 62 per cent.
Working as we do on cerebral palsy cases, which generally result from a delay in delivering a baby expeditiously, the team here knows only too well from medical records presented in evidence that too often hospital staff on labour wards either fail to respond to suspicious CTG readings quickly enough to prevent a baby being deprived of oxygen in vitro, or they simply do not notice the warning signs at all.
Clearly, in most labour wards, midwifes and other medical professionals are caring for several women at once. But CTG monitoring to accurately record the baby's heart rate is the front line of alerting staff when a baby is in distress and needs to be delivered. This is an absolutely fundamental aspect of maternity care.
I recently settled a case involving a now six-year-old girl with cerebral palsy born at the Conquest Hospital in East Sussex.
Despite her mother telling midwives that she was experiencing swollen hands and feet, headaches and heartburn weeks before delivery and that a few days before she was passing blood clots, delays in performing a C-section resulted in her daughter suffering brain damage leading up to her birth.
High blood pressure should have alerted staff to the possibility of pre-eclampsia, plus it came to light in evidence that one of the midwives had noticed that the CTG trace was dipping and had called the consultant obstetrician who was unsure how to interpret the readings.
Although she initially made the decision that the mother should be prepped for a Caesarean, once medication to lower her blood pressure kicked in, the consultant decided instead to progress with a natural birth and to attempt to break the mother's waters.
Catastrophically, once it became clear that this was the wrong decision, a caesarean was too late to prevent injury to the baby.
We eventually achieved settlement of £25m to provide the care this child now needs to enable her to fulfill her potential. She is currently doing well at school, is learning to feed herself and can communicate with her family. However, she continues to suffer from distressing seizures which involve her not breathing and struggles to stand for any length of time.
The tragedy is that fetal monitoring was in place, but vital discrepancies were simply not picked up quickly enough nor acted upon. One of the specialist midwives we frequently use to assess negligent procedures commented recently that getting the basics right is absolutely fundamental to protecting mothers and babies.
Let's hope that these recommendations included in the report will effect change.
- All families should be offered an open and full conversation about their care, which should include an apology in line with the duty of candour and setting out the investigation process and how they can be involved;
- There is an urgent need for an evidence-based, standardised approach to fetal monitoring in England. Effective improvement strategies for fetal monitoring require in-depth understanding of the social mechanisms underpinning the process, not just the technical issues. Research in this area should be prioritised urgently;
- Increased awareness needed of impacted fetal head and difficult delivery of the fetal head at caesarean section, including the techniques required for care;
- Work with existing national programmes to improve the detection of maternal deterioration in labour, including monitoring as well as the implementation of evidence-based guidance in all birth settings; and
- Awareness of the importance of high-quality resuscitation and immediate neonatal care on outcomes for newborn babies. This requires collaboration between the whole multi-professional team.