By: 4 October 2019
Learning from avoidable brain injuries at birth

NHS Resolution has reported on the first year of its innovative scheme to drive improvements in maternity and neonatal services and to ensure that families are better supported whose babies suffer rare, but tragic, avoidable brain injuries at birth.

The Early Notification scheme progress report: collaboration and improved experience for families provides an overview of the scheme to-date alongside a thematic analysis of a cohort of cases from year one of the scheme (2017/2018).

Previously, the average length of time between an incident occurring and an award for compensation being made was 11.5 years, with claims often not notified to NHS Resolution until four to five years after the incident and compensation paid when the full extent of injuries were apparent. A key ambition of the EN scheme has been to shorten the time taken to report an incident from years to days, to enable learning to be identified quickly and support to be provided to families when they need it most.

As a result of the scheme families have been provided with:

  • a detailed explanation;
  • an apology;
  • sign-posting to independent representation; and where an entitlement to compensation has been identified;
  • prompt financial support for clinical and respite care; and
  • psychological support where required.

Early admissions of liability have been given to 24 families within 18 months of the birth.

NHS Resolution is working in partnership with other national organisations including the Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, the National Maternity Safety Champions and NHS England and NHS Improvement through the Maternity Transformation Programme to support the Government’s target of halving the rates of stillbirths, neonatal/maternal deaths and brain injuries associated with birth by 2025.

The report makes six recommendations to support the clinical issues identified in the research covering topics such as how families are treated when things go wrong, to monitoring in labour, and awareness of risk factors of brain injury at birth.

Common themes in 96 case were explored and included limited support to staff, a lack of family involvement, and confusion over duty of candour and:

Cases Contributory factors
70% Issues with fetal monitoring
63% At least two or more factors were identified (problems with delay acting on a pathological CTG the most common factor)
32% Immediate neonatal care and resuscitation remains an important but an under-recognised factor
9% Impacted fetal head and/or difficult delivery of the head at caesarean section. This is a high-incidence for a problem that has not previously been reported by us.
6% Concurrent maternal medical emergencies in labour including significant maternal hyponatraemia were important contributors to neonatal seizures and encephalopathy

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. When the unthinkable happens, it’s imperative Trusts are able to have these important but difficult conversations, and frontline staff have the support and skills to deliver this candour with confidence.”

Dr Samantha Steele, lead author and National Obstetric Clinical Fellow at NHS Resolution said: “Having a baby should be a positive experience for families but sadly things do occasionally go wrong in maternity care with devastating effects. By carrying out early liability investigations, we can improve the experience for families and staff affected, provide early support and reduce formal litigation in the courts and the associated legal costs. Proximity to incidents also enables time relevant learning to be identified and shared at a national, regional and local level.”

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: “We welcome the publication of this report and the benefits that the Early Notification scheme may provide for the system, maternity teams and families. 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. The RCOG is committed to working closely with the NHS, Royal College of Midwives and other partners to provide further national guidance and training for maternity teams to reduce the risk of avoidable harm.”

Commenting, 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. The RCM remains committed to improving safety across our maternity services and is working in collaboration with the RCOG to support the Government’s target of halving the rates of stillbirths, neonatal and maternal deaths and brain injuries associated with birth by 2025.”

Appendix one

The report makes six recommendations:

  1. All families, whose baby meets the Early Notification criteria and requires treatment and separation from them for a potentially severe brain injury, should be offered a full and open conversation about their care. This should include an apology in accordance with the statutory duty of candour, a description of the intended investigation process and options for their involvement in investigations.
  2. An independent package of support should be offered to all NHS staff to manage the distress that can be associated with providing acute health services and in particular those involved in incidents. Support should address mental health, wellbeing and post-incident care with access to referral for psychological assessment and intervention where required.
  3. There is an urgent need for an evidenced-based, standardised approach to fetal monitoring in England. Effective improvement strategies for fetal monitoring require in-depth understanding of the social mechanisms underpinning the process, not just the technical issues. Research in this area should be prioritised urgently.
  4. Increase awareness of impacted fetal head and difficult delivery of the fetal head at caesarean section, including the techniques required for care. Research to understand the prevalence, causes and management of impacted fetal head is a priority, along with effective training in the management techniques.
  5. Work with existing national programmes to improve the detection of maternal deterioration in labour, including monitoring as well as the implementation of evidence based guidance in all birth settings. Research to understand the prevalence and cause of significant hyponatraemia in labouring mothers in England should also be prioritised.
  6. Awareness of the importance of high-quality resuscitation and immediate neonatal care on outcomes for newborn babies. This requires collaboration between the whole multi-professional team.


For more information, visit: NHS Resolution

Image credit: Credit:Chinnapong