A report published by the Royal College of Obstetricians and Gynaecologists which investigated recent neonatal deaths and injuries concludes that three in every four of those babies may have had a different outcome had they received different care.
Following the recent exposure of preventable neonatal deaths and birth related brain injuries at Shrewsbury and Telford Hospitals NHS Trust, the findings of the Royal College inquiry – Each Baby Counts - are equally troubling, suggesting that the issues highlighted in Shropshire remain widespread.
The report, which examined 1,136 stillbirths, neonatal deaths and brain injuries in UK maternity units in 2015, indicates that 282 babies died before or shortly after birth (of those 126 were categorised as ‘stillborn’) and 854 had a severe brain injury which may have long lasting consequences.
Local investigations into a quarter of the cases were not thorough enough to allow the report authors to do a full assessment of what might have gone wrong. In many of the 727 cases that could be reviewed in-depth, problems with accurate assessment of foetal wellbeing during labour as well as staff understanding of handling complex situations were cited as significant factors.
Chief among those failures in the assessment of foetal wellbeing during labour cited by the inquiry was misinterpretation of the baby’s heart rate patterns on traces from cardiotocography (CTG) machines. Failure to correctly use or interpret the traces from CTG equipment was at the heart of the criticisms levied at Shrewsbury and Telford Hospitals NHS Trust and was also highlighted as a problem as far back as 2012 in an NHS Litigation Authority (now NHS Resolution) 'Ten Years of Maternity Claims' report.
That review suggested that 46% of claims involved failure to recognise an abnormal CTG and a further 40% of claims resulted from a failure to act upon those CTG readings. That was certainly true in two high profile cerebral palsy cases Shoosmiths dealt with – Milly Evans and James Robshaw.
Shoosmiths has a team of specialist solicitors across the UK who represent children who have suffered a brain injury as a consequence of such failures. Denise Stephens, the partner in the firm’s medical negligence team who handled both the Milly Evans and James Robshaw cases (achieving compensation awards of £10.8m and £14.6m respectively) comments:
‘The UK remains one of the safest places to give birth and we often see excellent standards of care in maternity units across the country. However, in a number of albeit rare but still entirely unacceptable cases the same basic errors seem to be made again and again. The consequences of simple failures to assess the baby during labour, or if CTG traces are not interpreted correctly, can be devastating and life long.’
‘The Royal College of Obstetricians and Gynaecologists’ report outlines how to prevent such tragedies in future. I would suggest that far more effective training and development of staff as well as better multi-disciplinary team working and greater mutual respect between obstetricians and midwives is needed. More senior staff should be made available during labour and junior staff should be given a better understanding about when to ask for help.
Funding should be provided to maternity units to enable them to put in place improved training programmes, particularly in the use and interpretation of CTG equipment, which would cost a very small fraction of the resources needed over a lifetime by seriously injured children, their parents and carers.’