Five years of cerebral palsy claim: A thematic review of NHS Resolution data (September 2017)

Summary

This report by NHS Resolution provides an in-depth examination of these rare but tragic incidents and the investigations that follow them. For the purposes of this study they focused on 50 cases of cerebral palsy where the incidents occurred between 2012 and 2016 and a legal liability has been established.

Working in partnership with other organisations, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, NHS England and NHS Improvement, NHS Resolution have highlighted areas for improvement and made clear recommendations to help trusts prevent further incidents.

The study draws upon the unique data set NHS Resolution holds to address two key areas for improvement: training to prevent future incidents and the quality of serious incident investigations.

Content

Key findings

There were 50 claims between 2012-2016 suitable for review.

• Potential financial liability could be greater than £390 million, which excludes the defence costs and the wider healthcare costs to the NHS.
• Evidence of poor quality serious incident investigations at a local level:
  • the patient and family were only involved in 40% of investigations
  • only 32% had a review that involved an obstetrician, midwife and neonatologist
  • only 4% had an external reviewer.
• Reports focused too heavily on individual errors.
• Errors with fetal heart rate monitoring was the most common theme. However, the underlying causes were often not related to individual misinterpretation but related to systemic and human factors.
• Breech births were over-represented within this cohort, compared to the national average.
• Inadequate staff training and monitoring of competency identified as an important issue.
• Shortcomings in informed consent evident.