Coroner’s Court Reform: Medical Examiners (MEs) system from April 2019
NHSR Cerebral Palsy Report – the good news and the bad news
The report of Michael Magro is a thematic review of NHSR data for the past five years starts on a positive note:-
• the NHS is the safest healthcare system out of 11 western countries
• giving birth in England is generally very safe
• in 2015 there were 664,777 live births and a trend of reducing rates of still births and neonatal deaths
• 3.39 still births per 1,000 birth and 1.71 neonatal deaths per 1,000 live births.
However, the conclusions to the report are not so encouraging.
The aim of the review was to identify clinical and non-clinical themes from CP claims, to disseminate shared learning and use it as a drive for change and quality improvement and to highlight the areas for improvement and evidence of good practice. The results were split in two parts:
• A lack of family involvement and staff support through the investigation process.
• Quality of root cause analysis was generally poor and focused too heavily on individuals.
• Due to the poor reporting quality, any recommendations were unlikely to reduce the incidents of future harm.
2) Listed specific concerns in
• Foetal heart rate monitoring.
• Breech birth.
• Staff competency and training.
• Patient autonomy.
There are 7 recommendations which can be summarised as follows:
- CTG interpretation should be part of a holistic assessment of foetal and maternal wellbeing. CTG training should incorporate risk stratification with timely escalation of concerns and the detection and treatment of deteriorating mother and baby.
- Trusts’ Boards must ensure all staff undergo locally led multi-professional training. Staff should not provide unsupervised care on the delivery suite until competencies have been achieved.
- Trusts should monitor the effectiveness of their training and link to clinical outcomes.
- The quality of SI investigations has been found to be poor. The HSIB (Health and Safety Investigation Board) should lead a working party to create national standardised and accredited training programmes.
- All cases of potential severe brain injury, intra partum, still birth and early neonatal death should be subject to an external or independent peer review.
- Women and families should actively be involved in the SI process.
- Adverse events can have serious negative effects on staff who need support at Board level with a “Maternity Champion” to ensure support for staff throughout an investigation irrespective of whether or not a claim occurs.
This was a limited study of 50 cases from 40 claims where liability was admitted but it reflects the same patterns which were present 25 years ago. In 1991 of 110 claims identified, 70% related to CTG abnormalities and interpretations. A 2004 review identified identical themes in the recording of maternal pulse, poor quality tracing, misinterpretation and inaction of which there were suspicious or abnormal CTGs.
The latest report provides useful lessons to be learned but the real question is does the organisation support organisational learning in the way in which OWAM an Organisation with a Memory 2000 envisaged?
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