NHS Resolution, the indemnity provider for the NHS, has recently published a report titled ‘Five years of cerebral palsy claims‘.
Following an analysis of 50 claims from forty NHS Trusts spanning four years, the report concludes that the number of babies born with brain injuries has not reduced, rather it has remained static.
“The evidence suggests that very little, if anything, has changed over the last 20 to 25 years.
“A 1991 review of 110 cerebral palsy compensation claims identified that 70% were related to CTG abnormalities and interpretation, while a 2004 review of medicolegal aspects with cardiotocography identified identical themes to this review – recording of maternal pulse, poor quality erratic tracing, misinterpretation, inaction with suspicious or abnormal CTGs and failure to incorporate the clinical picture.”
The report states that the key reason for there not being a reduction in babies born with Cerebral Palsy at birth is that lessons are not being learnt. The report highlights poor quality Serious Incident investigations at local trust level following negligence in maternity care.
“The quality of Serious Incident investigations has repeatedly been found to be poor with very little or no training for investigators across the NHS”.
Furthermore, 60% of internal NHS investigations do not involve the parents.
“In six out of ten cases we found that women and their families were not being involved in investigations. Where families can, and are willing to participate in investigations, they bring a unique perspective and invaluable insight as to what went wrong. We recommend that serious incident investigations should not be closed unless the family have been actively involved throughout the investigation process or else have explicitly confirmed that they do not wish to be involved.”
Although obstetric claims account for around 10% of the claims NHS Resolution deal with, they account for 50% of the value because of the extent and nature of some injuries and the long term care needs. More importantly, the question remains, why are lessons not being learned when the impact of Cerebral Palsy is so devastating on the patient and their family?
The Chief Executive of NHS Resolution, Helen Vernon has said:
‘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 the steps that we and our partners have committed to as a result, represents a vital step towards preventing future harm.’
With little change in the last 25 years, one hopes that significant steps are now taken and lessons are learnt.