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Maternity matters – learning lessons from early notification

26 September 2019

NHS Resolution has released a report on the first year of the innovative Early Notification (EN) Scheme. The Early Notification scheme progress report: collaboration and improved experience for families draws together key themes and recommendations from an analysis of cases from the first year of the scheme (2017/2018).

The EN scheme, launched in April 2017, aims to improve safety in maternity care through the early investigation of incidents where babies are born at term, following labour, with a potentially severe brain injury. It epitomises NHS Resolution’s strategy to do more, closer to the point of incident.

Early investigation of these cases helps families to be supported when they need it most with an early apology for what has happened and answers into what may have gone wrong, together with an early decision on liability and compensation where appropriate. As a result of the scheme early admissions of liability have been given to 24 families within 18 months of the birth. Previously the average length of time between an incident occurring and an award for compensation being made was 11.5 years.

A key aim of the scheme is also to identify learning that can be fed back to ensure that immediate lessons are learned to avoid future harm. Common themes from the first year of the scheme included problems with monitoring fetal heart rates during labour (a factor in 70% of cases), and avoidable delays in expediting birth (63% of cases). The report highlights two emerging clinical issues including impacted fetal head at Caesarean section and the identification of maternal/fetal hyponatraemia. 

The report makes six key recommendations;

  • Full and open conversations with families about their care and the investigation process. 
  • An independent package of support for NHS staff 
  • Urgent research into a standardised approach to monitor fetal heart rates 
  • Raised awareness and research into difficult delivery of the fetal head at Caesarean section
  • Improved detection of maternal deterioration in labour including hyponatraemia 
  • Raised awareness of the importance of high-quality resuscitation and immediate neonatal care on outcomes for newborn babies. 

It is vital that the valuable insights, findings and recommendations from this report are shared across the maternity network to support the work being done to improve care and birth outcomes. If you would like any more information about the EN scheme or what your organisation can learn from the EN report, please contact Sian Brown, Senior Associate – 0330 045 2875 or sian.brown@brownejacobson.com

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