Cerebral palsy claims: NHS Resolution publishes thematic review
NHS Resolution’s five year strategy 'Delivering fair resolution and learning from harm' focuses on prevention, learning and early intervention to address rising costs of harm in the NHS. In accordance with that strategy, NHS Resolution published its thematic review of 'Five years of cerebral palsy claims'.
The comprehensive report looked at data from 50 cerebral palsy claims brought against NHS Trusts between 2012 and 2016 where liability had been admitted. The review also considered external publications and reviews.
NHS Resolution and Darzi Fellow Dr Michael Magro (the author of the report) should be congratulated for a very learned and useful report to be used by maternity teams around the country as a source of learning and improvement.
Of all injuries suffered due to negligent care, cerebral palsy typically has the most devastating life-long effect on the injured baby, their family and the NHS staff involved in the delivery.
Accordingly compensation arising from cerebral palsy claims is very significant and continues to increase due to changes in the discount rate, increased life expectancy and increased costs in relation to care and accommodation. It will not be unusual for awards in excess of £20,000,000 to be made per claim, following the Lord Chancellor’s reduction in the discount rate from 2.5% to -0.75%. In 2016/17 obstetric injuries, such as cerebral palsy, accounted for only 10% of claims brought against NHS Trusts but amounted to 50% of the total monetary value of all claims (£4.37 billion).
Areas of concern
The thematic review focusses on two fundamental areas of concern:
- Inadequacies of serious incident investigation reports
- Clinical areas of concern.
Serious incident investigation reports
The report raises concerns over the quality and inclusiveness of investigation reports carried out subsequent to a poor outcome delivery.
In particular the report identifies a lack of family involvement in the investigation process. It is noted most parents would like the opportunity to participate yet only 40% of investigations involved the family and, in 16% of cases, there was complete failure to undertake an investigation until a claim was pursued. Despite liability being admitted in all 50 cases, an apology was only provided in 64%, despite NHS Resolution promoting “Saying Sorry” for the last two decades.
The quality of root cause analysis is also criticised for being too focussed on individuals rather than systems. The most frequently identified causes for injury were individual skill levels (52%) followed by poor communication (44%). The report criticises NHS Trusts’ failures to investigate or explain why the event occurred. It is suggested the quality of investigation reports is improved with input from obstetricians, midwifes and neonatologists, yet only 32% of reviewed cases involved all three specialisms.
The review notes recommendations in investigation reports are frequently unlikely to prevent a recurrence and do not focus on the creation of plans which will improve safety. Evidence strongly suggests improving systems, rather than focussing on individuals is the key to patient safety.
Clinical areas of concern
The report identifies four common clinical themes which require addressing by NHS Trusts:
- Errors with foetal heart rate monitoring
- Breech birth
- Inadequate quality assurances around staff competency and training
- Patient autonomy and informed decision making.
Foetal heart rate monitoring - 64% of cases involved errors with foetal heart rate monitoring, including misinterpreting CTGs, failing to timeously commence CTG trace, false reassurance and slow response to pathological trace. Interestingly, additional CTG interpretation training did not reduce the rate of cerebral palsy and the report suggests a wider strategy and alternative methods to identify at risk deliveries should be explored.
Breech births - breech births accounted for 12% of cerebral palsy cases within the review and simulation training in obstetric emergencies is proven effective in reducing poor outcomes.
Training needs - 58% of claims reviewed identified additional training needs within the investigation report. Notably, the desired training frequently identified was not new training, but training previously available but not undertaken. The report champions the message ‘those who work together should train together’ and recommends midwives, obstetricians and other professionals train together to improve standards.
Patient autonomy - failures to obtain informed consent, including failing to provide sufficient information for potential risks or alternative options is highlighted as a cause of poor outcomes. Communicating sufficient information to enable patients to make an informed decision is proven to reduce poor outcomes, in particular in relation to the decision to undergo Caesarean section.
It is hoped dissemination of the review will help Trusts identify clinical and non-clinical themes which are proven risk factors for cerebral palsy claims, improve shared learning between Trusts, drive change and highlight potential solutions resulting in a safer environment and better outcomes. A safer environment should also lead to a reduction in claims so funds can be diverted back to patient care rather than litigation.