Babies damaged by poor heart rate monitoring in labour – study

The failure of midwives to adequately monitor foetal heart rates during labour is a major factor in why babies suffer brain damage in cases of poor care, a report says.

The new study, from NHS Resolution, found that a delay in delivering babies showing signs of distress was another key reason why infants ended up with avoidable brain damage.

Furthermore, experts found that many NHS trusts failed to offer parents an apology when things went wrong, and under-estimated how often their poor care had led to harm.

The NHS Resolution early notification scheme has been designed to provide swift answers for families while cutting the huge NHS compensation bill.

It involves hospitals alerting NHS Resolution where there is a potential legal claim for a child injured during birth.

Experts from NHS Resolution then assess the cases and, where necessary, make an early admission of liability and give families prompt financial and emotional support.

The new study included 197 cases where NHS Resolution panel solicitors were instructed to investigate liability, with 96 cases examined in depth.

Issues with foetal monitoring was a leading contributory factor in 70% of the 96 cases.

In 60 cases (63%) there were avoidable delays in delivering the baby, with around a third of mothers waiting over an hour despite problems being detected.

Overall, the most common contributing factor in causing a delay was staff failing to escalate the problem, or a delay in acting upon abnormal foetal heart rates.

In 9% of the 96 cases, there was a difficulty delivering the baby’s head or the baby suffered an impacted head during a Caesarean section.

Experts also looked at the involvement of families in 92 of the cases.

In 77% of cases, families were notified by the trust that an incident had occurred, but only 35% were recorded as having been offered an apology – something the experts described as “concerning”.

Only 30% of families were invited to be actively involved in an investigation, while 43% of families were informed of NHS Resolution involvement in their case.

Some 125 cases were initially assessed by NHS hospitals to be “unlikely” to be associated with sub-standard care.

However, these were reviewed by an internal NHS Resolution team, with 56 cases (45%) then revised upwards to “possible” or “likely” to have involved sub-standard care by NHS teams.

Before the early notification scheme was set up, the average length of time between an incident occurring and an award for compensation being made was 11.5 years.

But, NHS Resolution said, in 24 cases in the report, early admissions of liability (within 18 months) were made and support was provided to families.

Health minister for maternity and patient safety, Nadine Dorries, said: “In the rare but devastating cases of brain injury in newborns, we’re determined to continually improve how we support affected families and ensure the NHS can learn immediate lessons to avoid future harm.

“The early notification scheme is helping parents when they need it most, ensuring they get the explanation and apology they deserve and access to fair representation and financial support sooner.”

Helen Vernon, chief executive at NHS Resolution, said: “Avoidable brain injury at birth, whilst rare, carries a cost to the NHS of billions of pounds in compensation payments and has lasting consequences for families, and the NHS staff involved.

“We owe it to them to learn from these cases to prevent the same things happening again and to provide support, right at the start when it can make a difference.

“This new approach is already delivering answers to families and recommendations for improvement to the NHS, cutting years out of the process and removing the prospect of litigation as a barrier to candour.”

Professor Lesley Regan, president of the Royal College of Obstetricians and Gynaecologists, said: “Every incident of avoidable harm is a tragedy for the family and distressing for the maternity staff involved.

“Alongside the need to provide families with prompt interventions and more post-incident support for staff, this report highlights the urgent need to develop more clinical interventions to prevent these incidents from happening in the first place.”

Gill Walton, chief executive of the Royal College of Midwives (RCM), said: “Every incident of avoidable harm leaves families devastated and affects midwives and maternity staff.

“Included in the report are recommendations around how women and their families are treated when things go wrong and also how staff can be supported, which is something the RCM really welcomes.

“For the vast majority of women and their babies, the UK is a safe place to give birth. However, despite the fall in stillbirth and neonatal mortality, avoidable incidents do happen.

“We want women and their babies to receive the safest possible maternity care so it’s vital we enable learning for improvements to safety and to reduce avoidable deaths.”