One year on: NHS Resolution reveals findings of the Early Notification Scheme

Posted: 02/10/2019

NHS Resolution has reported following the first year of its Early Notification Scheme, which was designed to drive improvements in maternity and neonatal services to ensure that families whose babies have experienced an avoidable brain injury at birth are better supported.

The Early Notification Scheme has been running since April 2017 and covers 129 acute maternity trusts in England.

From April 2017, all maternity trusts have been required to report, within 30 days, maternity incidents of potentially severe brain injury so that NHS Resolution can review the findings to ascertain how future incidents can be prevented.

The report looks at the data captured where babies have been born with potentially severe brain injury following labour, at term.

The scheme is part of a government plan to halve rates of stillbirths, neonatal/maternity deaths and brain injuries linked with birth by 2025.

Previously, the average length of time between an incident occurring and an award for compensation being made was 11.5 years. Claims were often not passed to NHS Resolution until a number of years after the incident, with compensation not paid until the full extent of injuries was apparent.

The aim of the Early Notification Scheme was to help families get support when they need it most and to enable trusts to learn quickly from the mistakes so that improvements can be implemented.

Following the introduction of the scheme, 24 families have received admissions of liability, a formal apology and in some cases, financial support, within 18 months of the incident.

The report findings

In the first year, over 800 incidents were reported to the Early Notification Scheme. Of these cases, the report looked at 96 cases deemed serious enough to receive full investigative and clinical analysis.

The key themes in the cases included limited support to staff, insufficient family involvement, and confusion over the duty of candour.

Importantly, the findings also revealed:

• 70% of cases involved issues with fetal monitoring as a leading contributory factor; in 63% of cases at least two or more factors were identified with a delay in acting on a pathological CTG trace being the most common factor; 
• difficult deliveries of a baby’s head during caesarean sections were a contributory factor in 9% of the cases; and
• in 32% of cases there were problems in neonatal care, such as the provision of immediate neonatal care and resuscitation, which contributed to the outcome.

Recommendations

Considering the findings, the report made six recommendations:

• All families, whose babies meet the Early Notification criteria and require treatment and separation from them for potentially severe brain injury, should be offered a full and open conversation about their care, including an apology and description of the investigation process.
• An independent package of support should be offered to all NHS staff, including a psychological assessment, to help those involved in the incidents.
• There is urgent research needed for an evidence-based, standardised approach to fetal monitoring in England and this should be prioritised.
• Awareness needs to be raised about difficulties in delivering the fetal head during a caesarean section, including the techniques required for care.
• Working with existing national programmes, improvements should be made in the detection of maternal deterioration in labour, including monitoring, as well as in the implementation of evidence based guidance in all birth settings.
• Awareness of the importance of high-quality resuscitation and immediate neonatal care for new-born babies should be raised, which requires a collaboration between the whole multi-professional team.

You can read the full report and the recommendations here.

A number of experts have expressed their views on the report with Professor Leslie Regan, president of the Royal College of Obstetricians and Gynaecologists, commenting: “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 findings of the report are promising as it reveals that early admissions are being given to families and, as a result of the scheme, these families are being given the support and guidance they need through such a traumatic time. The scheme has also identified where the problems lie in the acute maternity trust in England to help identify where learning and training and research is required.”

Alison Appelboam Meadows, partner and member of the birth injuries specialist team at Penningtons Manches Cooper, said: “We represent families whose children have suffered brain injuries at birth and therefore have experience in investigating at first-hand what went wrong in these cases and guiding parents through the process. The families who we represent are often not given answers and it can take a great deal of time for them to receive compensation to provide the care and support their child requires. The report is a step in the right direction in helping families from the initial incident onwards and in encouraging a more open culture. It will also identify key areas where improvement is clearly needed and lessons need to be learned quickly to avoid future harm and families suffering in similar circumstances which could potentially have been avoided.”

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