The single most important reason why UK maternity liability claims are skyrocketing

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Last month I wrote a series of posts about the decision by the Royal College of Midwives to shutter its Campaign for Normal Birth. Although the RCM leadership denied it, some going so far as to claim dead and injured babies are “fake news,” the campaign was stopped because of skyrocketing rates of maternity liability claims. Indeed nearly £2bn was paid out in compensation in the past year alone.

A just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data, investigates those claims. The report is detailed, comprehensive, and contains multiple valuable recommendations. It also identifies the single most important reason why UK maternity liability claims have been skyrocketing: perinatal deaths and injuries aren’t being properly investigated.

Perinatal deaths and injuries aren’t being properly investigated.

As the Executive Summary of the report notes:

The quality of root cause analysis was generally poor and focused too heavily on individuals.

Due to the poor report quality, the recommendations were unlikely to reduce the incidence of future harm.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The gold standard for investigating errors is Root Cause Analysis (RCA).

It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

Determine what happened.
Determine why it happened.
Figure out what to do to reduce the likelihood that it will happen again.

Although RCA can provide information and closure for families, it’s primary purpose is to identify modifiable factors that can be improved in order to prevent future bad outcome.

As the NHS Report notes:

A RCA should be logical, fair, open and adopt a just, or fair blame, culture, as it is often a system failure rather than an error by an individual that is at fault. It is therefore vital that a RCA looks at the wider environmental and organisational factors, often referred to as latent conditions, that allowed the error to occur.

In other words, rather than seek to blame individual bad actors, an RCA looks for systemic failures. In contrast, internal investigations of NHS maternal liability claims focused on assigning blame, not the root causes.

Looking at the root causes within the reports, it appeared that the question of why the incident happened, or was allowed to happen, is often missing…

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The root causes identified in the reviewed cases included:

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The most common contributing factors were poor individual skill level and failure to communicate with others.

Why was the pathological CTG managed incorrectly? What went wrong with the undiagnosed breech and why did that result in CP? Why was the scan incorrect? Was it inadequate training, a faulty machine, that the operator was distracted? Why did a woman with a concealed abruption have a baby born with CP, remembering that these 50 claims are due to admitted clinical negligence, so what went wrong with her care?

No attempt was made to address these critical questions.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

This is not new information:

The Kirkup report identified significant systematic and organisational failures which the Morecambe Bay hospitals own SI investigations and RCA process missed, as they were “rudimentary, over protective of staff and failed to identify underlying problems…”

The RCOG EBC project identified that 25% of local reviews did not contain sufficient information to allow the care to be classified. Of those reviews that were of sufficient quality, just over 60% of investigations used a RCA methodology, while 21% contained no actions or recommendations and 23% recommended actions focusing solely on individuals.

The CQC report demonstrated a worse picture within acute trusts. Only 8% of reports demonstrated evidence that a clearly structured methodology was used, which would identify the key issues, contributing factors, system issues and causal factors that led to the incident…

As the parent of an injured baby explained:

It feels like the priority of the serious incident process is damage limitation rather than learning from mistakes. What makes this even worse is the lack of learning both by the trust and the wider NHS from what happened. The problem with the quality of the report… is that its purpose was not to blame individuals and was to nd a root cause [but] it stopped at individual mistakes and not once did it ask why people made these mistakes.

“The frustration from our case is that if a proper root cause had been found, such as training not being given or procedures not being known then it would not just stop similar cases to ours but could reduce serious incidents across the trust.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

If there is no serious attempt to identify modifiable systemic failures, the same failures will occur over and over again. And that is precisely what has occurred.

It appears that the individuals involved were expected to follow guidelines that were in place the next time a similar incident occurred, without identifying why they were not followed in this instance. Identifying an issue with the guidelines that could be changed may result in better care for someone else.

This is not new information, either.

The findings of this review are very similar to those identified within the RCOG EBC programme, that only 56% of the investigations they analysed had actions or recommendations that took a systemic approach, 23% focused solely on individuals, often to attend training, and 21% contained no actions or recommendations.

The CQC report on SI investigations also highlighted the same problem. They found that “too many reports concluded that the actions of staff were the key causes of the incident” and many investigations focused their recommendations on staff failing to “follow trust policy and procedures.” Only 35% of investigations had recommendations that could reduce the risk of recurrence and many focused on reminding staff be more vigilant or to follow guidelines.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The Report makes a critical recommendation:

In line with the Kirkup and RCOG Each Baby Counts reports, all cases of potential severe brain injury, intrapartum stillbirth and early neonatal death should be subject to an external or independent peer review.

If those responsible for understanding why deadly errors occur either can’t or won’t identify systemic causes, review should be undertaken by external, independent panels.

Unless and until that happens, babies will continue to be injured and will die and the NHS will continue to bleed money on liability claims for preventable errors.

  • Young CC Prof

    The only thing worse than learning from fatal mistakes is making fatal mistakes and not learning from them.

  • fiftyfifty1

    Imagine learning that your baby should not have died, that your baby would be alive and in your arms right now if only your care providers had done things correctly…then imagine finding out that nothing had been learned, nothing had changed and your baby’s death was entirely in vain. How do these poor parents keep from going insane?

  • Squillo

    Due to the poor report quality, the recommendations were unlikely to reduce the incidence of future harm.

    That’s one of the most damning phrases I’ve read in a healthcare document. If you have more than one or two preventable deaths, the problem isn’t “a few rogue midwives” (as some have contended) , it’s systemic. If there are more than a dozen, it’s pervasive.

  • CSN0116

    Seems as if routine third trimester ultrasounds could save them a bundle, per the list of root causes included above.

    • Kelly

      I really wish third trimester ultrasounds were routine. I have been able to have one for each of my children for different reasons. I think that the doctors feel the same way and would take any small concern and use it as a way to do check the baby. None of mine were actually necessary but that is only known with the ability of hindsight.

      • Quende

        So… in the UK women get no ultrasounds in the third trimester? Not even to make sure there were no changes in the baby’s position or in the amount of amniotic fluid? Not even when they are admitted to the hospital to give birth? I have no words.

        • Lilly de Lure

          Not routinely but it does depend on circumstance – I was offered them because I was at high risk from IUGR for example and they kept on scanning my baby’s cord because they weren’t convinced it was working right (whether they wanted to do anything about it when they found evidence that all was indeed not right was another story entirely of course).

        • TheArtistFormerlyKnownAsYoya

          Not in Canada either. 18-20 week anatomy scan, no more after that.

        • mabelcruet

          Not routinely. The normal schedule is a dating scan in the first trimester and the anomaly scan at 20 weeks or so. In the UK, there are various options available for expectant mothers-you can have midwife led care, shared care, or consultant(medical) led care. Consultant led care is generally for those women who have complex pregnancies for whatever reason. Women can be transferred to consultant led care if issues arise during the pregnancy, and will get scanned again if needed (for example, if there are worries about fetal growth), but on the whole there isn’t a ‘routine’ scan in the 3rd trimester. Scans will be done to assess fetal position if palpation suggests that’s an issue, and done if there is a question of premature membrane rupture, but not as a routine if there are no clinical signs.

          • American, but wondering

            What about women who want elective c-sections? Do they have a way to escape from the midwives into consultant care?

          • maidmarian555

            I’m having an elective section next week and haven’t actually seen a single consultant at all. I won’t meet the OB delivering my baby until the day before or possibly on the day of the surgery. Technically I’m on a consultant-led care pathway but in practice, where I am, that seems to mean that you get midwife-led care (even my meeting at the hospital to get the section signed off was with a midwife). Friends who’ve needed sections for complications etc have seen actual doctors but not me.

          • Lilly de Lure

            Snap – I was consultant led care and didn’t see a single one until I was actually admitted into hospital.

          • Roadstergal

            Oh, wow, already! I hope it all goes smoothly and we’re congratulating you on your new family member next week!

          • Roadstergal

            (Do you have a baby now? 😀 )

        • Azuran

          I really depends on circumstances, It’s on an individual basis. I ended up having 3 because the first scan showed a limit kidney size so they checked a month later, and I had a third one because I measured larger than normal.
          My colleague had a super high risk pregnancy, she basically had one every single week.
          Most of the time, the baby’s position is palpable, if they have a doubt they will do one. But if everything is going smoothly and there is no sign of anything wrong, having ALL the pregnant women have a third trimester US will cost money, clog the system and will probably not give much results.
          I really doubt that overall, many baby would be saved ONLY because they had a third trimester scan.

        • Kelly

          I am in the U.S. and I had one for low fluid, I asked if the baby was breech and got a scan on the next appointment, and for my last, for not gaining enough weight. All of my scans were highly accurate for the weight of the baby as well. All were scheduled for specific reasons and not as routine.

          • Dr Kitty

            I got third trimester ultrasounds with both of mine.
            First time because I saw an OB who is a family friend, and he had a very specific estimated weight range he was comfortable with me trying to deliver. The second time because of the risk of IUGR ( both of my babies are on 9th centile).
            Both times scans overestimated their weights by at least a pound.
            I didn’t mind with the first, because it meant my OB leant towards CS to avoid CPD (he didn’t think I could deliver a baby over 7lbs, which was what the scan estimated at 38w), but it was falsely reassuring with #2 “oh no, this baby is going to be at least a pound bigger than your first”!

            #1 6lbs 3oz at 38w5d
            #2 6lbs 5oz at 39w.

            I do not make big babies, but they have absolutely normal weight trajectories until the very end.

            SFH is useless for me- I’m very short with a wonky spine. My belly goes OUT because it can’t go anywhere else. I consistently measured on 90th centile for both pregnancies, with normal fluid volumes on scans, and little babies.

          • Kelly

            I have heard that figuring out weight with ultrasound can be hard and not reliable so I was surprised when they were accurate for my babies.

        • Anj Fabian

          One of the problems from patient reporting (aka internet anecdotes) is that even when a ultrasound shows an anomaly like low AFI, the patient isn’t referred for additional services like a CTG.

          They might be told to come back in a week or two for another scan.

          It’s frustrating. If nothing happened after the first scan, what will happen after a second scan?

          The patient is usually told to come in if they have concerns like reduced fetal movement, but again, the response to that is often feeble.

          • Lilly de Lure

            Amen sister – you start to wonder what is the point of collecting evidence of a problem if they haven’t the slightest inclination to actually do anything about it!

          • Steph858

            Pretty much this happened to me (IUGR was the concern). The following conversation ensued:

            Me: How long should I wait for him to start moving before I come in?
            Them: Well, that depends on what’s normal for his movements.
            Me: Well, he likes to go all day without moving then, just when I’m starting to worry and thinking about coming in, he’ll start tap-dancing for 2 hours straight.
            Them: …

            Result: I was kept in overnight. I spent almost the whole week before my son was born in hospital.

        • Quende

          Thanks for all the information, everyone. I was surprised because my experience was very different (Czech Republic). In my country pregnant women have monthly check-ups with their GYN and nowadays almost everyone have an ultrasound in their office and usually would use it to check how the baby’s doing – at least, that’s what my doctor did. Naturally, I got the big first trimester screening and the anatomy scan at 20 weeks. In the last month before due date, you have check-ups every week at the hospital you’ve chosen to give birth at. I remember having at least one ultrasound (I remember they measured the baby’s size and head circumference, and checked the placenta).

        • Sarah

          Anecdotal experience for myself and friends is that it’s not particularly difficult to get one (or more) in the third trimester if there are any concerns, even relatively minor. However it’s not routine. I had one pregnancy where the suggestion was never even mooted, and another where the midwife was very concerned about me being big but not unusually so and insisted on me being put in as an emergency. I have friends with similar stories and with high risk pregnancies, obviously they tend to want you in a lot.

          Private scans are also becoming more common, though more because people want to see what the baby looks like than anything else. I expect those would pick up potential problems too, but of course they require you to have the money for one which not everyone does.

    • Young CC Prof

      The OB I had with my first baby had a policy of combing medical records until she could find a risk factor to justify a 3rd trimester ultrasound. That ultrasound was the only way we found out my baby had IUGR. He was delivered by calm, planned CS at 37 weeks, skinny but healthy–with a placenta that was close to shutting down.

    • lsn

      I had to go and look at what happens here (no idea what happens in ‘routine’ pregnancies after 20 weeks.) Same deal – 12 week ultrasound, then 20 week. I have to say that including another one at the 33-35 week mark would have prevented quite a few women I know from having a stillborn baby.

    • Abby

      I think people would rather just wring their hands and wonder why our still birth rates are so so high than do anything expensive and practical like this in the UK. Basically having a baby here is pretty much keep your fingers crossed, if you have any concerns about feral movements or pain etc you will be patted on the head and patronisingly dismissed as a neurotic first time mum, which luckily most of the time will work out ok, but sometimes it won’t and then the establishment shakes its head and says ‘but why do we have so many still births compared to other countries?????’

      • Abby

        Fetal even!

      • AnnaPDE

        Oh they’ll also have heartfelt articles about how you should count kicks and whatnot, in order to “take responsibility” for your baby’s wellbeing, while conveniently forgetting to mention what usually is done in practice if the count does seem a bit off to you: Nothing.

      • Lilly de Lure

        Yep – I’ve even heard midwives remarking that they wish that women weren’t even told about counting the kicks as the whole thing was just “fear-mongering” and led to full triages and women who didn’t trust their bodies. The fact that it could also save a baby’s life (and might save more if they would only take it seriously more often) was evidently poor compensation for such drawbacks.

        Edited for grammar errors

        • Abby

          What you have to remember is that most (not all) uk midwives are profoundly irritated by pregnant women probably as they are over stretched and understaffed, but there is a definite kernel of contempt there as well.

          • MaineJen

            “Profoundly irritated by pregnant women.” …Midwifery does not seem the best career choice, then?

          • Lilly de Lure

            I think the issue may be that they have their ideal pregnant woman – confident, assured, determined to go natural all the way (and of course healthy and low risk) n mind when they go into midwifery and find us mere mortal pregnant women are a sad let down compared with these angelic creatures (particularly the worried types who show up in triage because the baby’s movements have stalled – the ideal pregnant woman would be meticulously counting kicks but would always have a great kick count, or would at the least “know” that her baby was fine and so would stay at home and out of the midwife’s hair).

    • AnnaPDE

      Hooray for my doctor who just has the ultrasound machine there in her practice, and openly states that her fee for 20mins of check is the same regardless of what she does, so we can as well talk while she’s doing a scan and taking cute photos.
      I can see how/why scans would be limited in places where an ultrasound is a rare and expensive device only available in select places. The UK is not one of these places — there’s heaps of ultrasounds around; maybe not the latest model everywhere but certainly enough to find out if the kid’s head or bum first.

      • Sarah

        It’s routine to have 2 ultrasounds during pregnancy in the UK, at around 12 and 20 weeks, and there isn’t as far as I’m aware a problem with ultrasounds only being available in select places. We have full coverage across the country, albeit I expect it’s a bit more difficult if you live in the Hebrides than if you live in a conurbation. But it’s not a geographic thing. We may of course need to add more models and sonographers in existing hospitals, but that’s a different issue.

        • AnnaPDE

          That’s kind of my point. You see an obstetrician (or at least midwife) more often than those two times in the course of a typical pregnancy, right? Especially when you get closer to the due date.
          So how good would it be if in addition to palpating and measuring with tape and taking your blood pressure and talking about whether you have any symptoms worth mentioning or worries, and whatever you do at your typical appointment… they also just had a quick look what’s inside using that already-existing ultrasound machine? Sure, it’s not a detailed fine scan, but it certainly helps pick up basic stuff like “this kid is breech”.

          Maybe it’s just my deformation professionelle speaking as a mathematician working with simulation models here, but using every available opportunity to collect easily accessible data that could contain some very important information seems like a total no-brainer to me.