Comment

20.12.17

Learning from when things go wrong

Source: NHE Nov/Dec  

Negligent care and poor training compliance can have a devastating effect on both patients and staff, writes Helen Vernon, chief executive of NHS Resolution.

When things go wrong in hospital it is important that lessons are learnt to prevent future harm. One area of focus for us is learning from harm in maternity cases.

Clinical negligence claims relating to incidents in maternity make up 10% of the number of claims NHS Resolution receives every year, but they represent around 50% of the expected cost of the claims. Overall in 2016-17 the total number of clinical negligence claims was 10,686. One of the biggest financial areas for claims is in relation to those for brain damage at birth.

Our figures show the number of claims for cerebral palsy and neonatal brain damage has remained relative static in the last 10 years, with 232 claims notified to us in 2016-17. Despite this, the financial cost for these types of claim has risen by 81% since 2004-5 – resulting in a total value of £1.9bn in 2016-17.

Factors that have led to this rise include increased life expectancy for those with cerebral palsy, as well as increased care and accommodation costs. Put simply, the costs keep getting bigger.

The majority of cases of cerebral palsy are not due to medical error. However, in rare and tragic occasions, it can be as a result of substandard care. In these situations there is always something to learn, and measures can be put in place to reduce the chances of them happening again.

Our report, ‘Five years of cerebral palsy claims: A thematic review of NHS Resolution data,’ highlights both the clinical and non-clinical issues that arise in such claims and makes recommendations to prevent them from happening again. It focuses on 50 claims for cerebral palsy where liability was admitted over the last five years.

The first clinical theme discussed in our report considers errors in fetal heart monitoring. Within this theme, the misinterpretation of the fetal heart trace was the most common error. As a result of this potential causes for concern were not picked up, and when they did become clear they were often not escalated quickly enough.

We have recommended that training should include a better understanding and grading of risk, along with more timely escalation of concerns. This should assist in more effective detection and treatment if the mother and baby deteriorate.

Other findings include a high proportion of breech deliveries which led to brain injury, as well as the need for improvements to the governance surrounding multi-professional training. Trust boards, alongside their obstetric and midwifery leads, must ensure that all staff undergo annual, locally-led multi-professional training. This should focus on integrating clinical skills with enhancing leadership and teamwork.

When an incident occurs, it is important the cause is thoroughly investigated. When we looked at the quality of investigations we found they often focus on the errors by individuals, when the underlying causes are often more systemic and relate to wider human factors.

It is important all those involved are included in the investigation, including families, if that is their wish. Our report, however, found when looking at incidents in maternity that in 60% of cases women and their families were not being involved in investigations. Yet we know where families can and are willing to participate they bring a unique perspective and invaluable insight into what went wrong. Our report recommends that such investigations should not close unless the family have been actively involved throughout the process, unless they have expressly said they did not wish to be involved.

We also found that in four out of 10 cases, staff were not offered support. Just as families and carers need help, we also have a duty to support NHS staff. These cases are tragic and can be traumatic for all those involved.

Overall maternity care is very safe, but there are areas in need of significant improvement. Negligent care resulting in cerebral palsy has a devastating and lifelong effect on the child, their family and carers. Whilst thankfully these cases are very rare, they can be prevented. What we have learned from these events and our recommendations represent a vital step towards preventing future harm.

FOR MORE INFORMATION

To read the report, visit:

W: resolution.nhs.uk/five-years-of-cerebral-palsy-claims

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