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NHS Resolution publishes 'five years of cerebral palsy claims'

19 September 2017

In line with its greater strategic focus on prevention and learning to improve safety, NHS Resolution has today published ‘Five years of cerebral palsy claims’. This report is a detailed, thematic review of 50 clinical negligence claims relating to cerebral palsy or neonatal brain injury which occurred between 2012 and 2016 and where liability has been admitted.

The report acknowledges the devastating human cost to the children involved and their families and carers in addition to the NHS staff involved, and highlights the significant financial cost to the NHS when litigation is pursued, contributing to pressure on funding and diverting much needed resources away from front line care.

This review is essential reading for those involved with patient safety and obstetrics. It analyses the most common themes in clinical care, specifically errors with fetal heart rate monitoring and cardiotocography (CTG) interpretation, a theme which has long been highlighted as an area for improvement.

The report also highlights common problems with the quality of serious incident (SI) reports. SI reports too often focus on individual staff failings without considering the wider organisational and/or environmental factors that enabled the error to occur, limiting learning and the opportunity to prevent future harm. This is illustrated by reference to SIs which identify CTG misinterpretation as a root cause when there are usually multiple and wider human factor issues at play. The report refers to the excellent video training resource produced by the University Hospitals of Leicester which aims to raise awareness of the importance of a human factors approach and enhance current methods of training for staff in this area.

The report makes seven key recommendations for improvements in the quality of SI reports and training of staff, building on evidence provided by a number of other high profile reviews and calling for changes to improve the current system and resources available for SI investigation. Crucially, however, this latest report goes further to outline what is needed nationally and locally for the recommendations to be implemented and leaves no doubt that significant changes are now required to benefit patients, families, carers, staff and the NHS as a whole.

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