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Maternity services resource hub and mock inquest films

abstract 

Maternity services across England are currently under intense scrutiny and there has been, and continues to be, a considerable focus on supporting NHS Trusts to learn from harm in a meaningful way to improve safety. This resource hub provides training materials and resources for NHS professionals to support organisations and clinical witnesses dealing with the improvement work underway in maternity units and the claims, inquests, regulatory and workforce issues that result from obstetric and neonatal harm.

Maternity mock inquest films

Browne Jacobson has produced a series of films to recreate an inquest hearing focussing on a neonatal death. The films explain the role of the Coroner and the purpose of an inquest and illustrate the procedure during a remote inquest hearing.

The clinical scenario is fictitious, and you can read the background here.

The aim of these films is to help clinical witnesses to prepare for giving evidence remotely and to illustrate how best a witness can help the Coroner and the family during a remote inquest hearing. We hope these films will support all clinical staff working in maternity services who are called to give evidence remotely at an inquest, so that they can give their evidence clearly, confidently and compassionately.

The films also bring out a number of themes that are often seen at inquests into neonatal deaths for learning purposes.

We are very grateful to Dr Robert Hunter, HM Senior Coroner for Derby and Derbyshire, for his role in the production of these films. Thank you also to the following NHS professionals who provided invaluable insights and appear in the films:

  • Kathryn Fearn, Associate Director of Legal Services, University Hospitals of Derby and Burton NHS Foundation Trust
  • Jo Hartley, Associate Director of Midwifery & Neonatal Services, Dorset County Hospital NHS Foundation Trust
  • Dr Ruth-Anna Macqueen, Senior Registrar, Obstetrics and Gynaecology, Barking, Havering and Redbridge NHS Trust
  • Lorraine Purcell, Head of Midwifery, University Hospitals Derby and Burton NHS Foundation Trust
  • Dr Jyoti Sidhu, Senior Registrar, Obstetrics and Gynaecology, Barking, Havering and Redbridge NHS Trust

View the video here >

This film explores the importance of consent discussions, particularly during the antenatal period, and the importance of good documentation.

The film begins with Mum’s evidence about requesting a caesarean section and then shows the obstetrician’s recollection of the discussions about mode of delivery with mum. Unfortunately, the antenatal discussions are poorly documented.

Consent is often a key issue in obstetric claims and if it is relevant to the facts of the death, its likely to be an area explored by a coroner.

The legal framework for obtaining consent is set out in Montgomery v Lanarkshire Health Board [2015] which makes it clear that a clinician is under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments, which in the context of maternity claims, includes the options for mode of delivery.

The importance of informed consent is highlighted in Ockenden preliminary review and Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.

Consent is not just a one-off process, there has to be ongoing dialogue and all discussions should be carefully documented.

View the video here >

The film illustrates some of the issues that can arise when a witness is poorly prepared.

It also highlights the problems caused by a failure to follow guidelines during the early stages of labour and confusion caused by a variation in the approach taken by clinicians to interpret the CTG.

Errors made during fetal monitoring remains a key feature of the claims and inquest landscape and is another issue highlighted by the Ockenden Report, with a requirement for Trusts to appoint a dedicated Lead Midwife and Lead Obstetrician both with demonstrated expertise to focus on and champion best practice in fetal monitoring.

Learning from claims often focuses on individual error in relation to the interpretation of the CTG but common themes include staff, or groups of staff, using a CTG categorisation or interpretation tool which is not in line with Trust guidelines. It is vital that all staff are properly trained and understand the importance of using a consistent categorisation tool and a systematic approach to CTG interpretation that is in line with local and national guidance. As highlighted in the Ockenden report, any deviations to this must be agreed within a multidisciplinary framework.

View the video here >

This film highlights the culture and power dynamics in this fictional maternity unit, which are demonstrated by tension between the midwife and doctor and the impact that this had on the care in this case.

As detailed in the Ockenden Report, Trusts must have clear standard operating pathways on when and how to escalate but there also needs to be a culture whereby staff feel able to escalate their concerns and understand that they will be listened to. This is not just about escalation from midwife to obstetrician, but also registrar to consultant. Creating an open and transparent culture where staff feel able to speak up will help Trusts to identify problematic practise before significant issues arise.

The film also emphasises the importance of organisational learning evidence at inquest to provide the Coroner with assurance so that the statutory duty to issue a Report to Prevent Future Deaths is not triggered. If an organisation can demonstrate learning from the death and evidence that action has been taken to prevent future harm in advance of an inquest this may avoid a PFD Report. However, as highlighted in the Chief Coroner’s updated guidance, PFD reports are not intended as a punishment – they are a learning tool, issued for the benefit of the public.

For further guidance on giving evidence remotely and to watch our Mock Inquest film visit our training page here and read our checklist here.

Witnesses may also find it useful to watch NHS Resolution’s films Giving evidence at inquest: a well prepared witness and How to prepare for an inquest, and also to read NHS Resolution’s leaflet entitled Inquests: Guide for Health Providers.

Maternity claims

Whilst claims relating to obstetric and potential neonatal harm make up a relatively low proportion of claims against the NHS overall (10% of the volume of claims received by NHS Resolution in 2019/20), the monetary value of these claims is significant, making up 50% of the total value of claims across all specialities. Claims relating to Hypoxic Ischaemic Encephalopathy (HIE) are some of the highest in value and not just in monetary terms, with tragic and devastating costs for patients and their families and often a significant emotional impact on the staff involved.

Although some cases of HIE are unavoidable, there are others where more timely delivery of the baby may improve the outcome and understanding and learning from what goes wrong in these cases is a key part of improving safety and outcomes and reducing the costs associated with litigation against the NHS.

Every case is different, but the following clinical themes are often present in the cases we are involved in resolving:

  • Errors in fetal heart monitoring
  • Failures/delays in escalating concerns leading to delays in delivery
  • Documented plans for review not being actioned
  • Lack of situational awareness
  • Shortcomings in the process to obtain consent
  • Shortcomings in communication and record keeping

Many of these issues are discussed in the Ockenden preliminary review published in December 2020 and which sets out seven ‘Immediate and Essential Actions’ (IEAs) for maternity units across England to implement in order to improve safety.

Support for maternity services

Our specialist teams can provide advice and support in relation to all of the legal, workforce and regulatory issues that arise from maternity incidents and to support organisations and clinical witnesses dealing with the improvement work underway in maternity units:

Our specialist health sector inquest and advisory team provides expert evidence on all patient-facing matters which affect NHS and private healthcare organisations. The team has outstanding experience of representing NHS and private healthcare organisations at inquests involving maternity care across the country. Located across each of our regional offices, our people are known and well respected by Coroners nationally. We are trusted by clients to provide user-friendly, straightforward advice and excellent representation in court and to support witnesses and organisations throughout the inquest process, having particular regard to reputational impact and prevention of future death strategy.

For more information please contact Rebecca Fitzpatrick, Nicola Evans or Simon Tait.

Increasingly, incidents in maternity services are attracting regulatory action from the Care Quality Commission, including actions against Trusts’ registrations and prosecutions resulting in substantial fines. Our Criminal, Compliance and Regulatory team includes a number of healthcare specialists, who can help guide Trusts through these processes.

We offer a seamless service with our inquest team able to work with regulatory colleagues during proceedings. This allows proactive advice to be provided to Trusts in respect of avoiding CQC enforcement action or preparing for scrutiny, including Well-Led inspections. We have represented Trusts in respect of CQC criminal investigations arising from maternity services as well as advising in respect of manslaughter and criminal neglect investigations. We have successfully challenged CQC draft reports, Warning Notices and the imposition of registration conditions.

For more information please contact Carl May-Smith.

When maternity incidents occur, they have a dramatic impact on the staff involved. There are many ways in which we can support Trusts to minimise and mitigate the effects on staff and the organisation as a whole. Creating an open and transparent culture where staff feel able to speak up will help employers to identify problematic practise before significant issues arise. We have a number of training packages which can be delivered to all levels of employee from front line workers to senior leaders. This ensures that freedom to speak up is embedded across the organisation and that every member of staff understands and is able to carry out their responsibilities to raise concerns.

When mistakes are made, we can support our clients to respond consistently with a just and learning culture looking, where appropriate, first at systemic or organisational problems before looking to place blame and sanction individual employees. In some cases, where there is evidence of misconduct or a lack of capability, there will be a need to take more formal action against employees. We regularly support our clients in conducting such processes, ensuring they adopt a compassionate approach which is consistent with the guidance and principles set out by Prerana Isaar, NHS Chief People Officer. We use our knowledge and experience of legal cases and sector guidance to develop bespoke training packages and to inform those tasked with conducting internal HR processes to avoid repeating mistakes that have been made in the past. We can give support at all stages of an internal process, from framing the Terms of Reference for an investigation to advising disciplinary and appeals panels.

For more information please contact Helen Badger.

Our specialist Risk Management team can support NHS Trusts by:

  • Providing insights into the themes and learning from the maternity claims and inquests we deal with.

  • Carrying out thematic reviews/deep dives of maternity incidents at your Trust, to support Trusts to identify any gaps and identify areas of focus for improvement work.

  • Delivering training on the key legal issues, including those arising from the Ockenden Report. For example, training at operational level covering issues such as consent, documentation and investigations or training at Board level, focusing on the roles and responsibilities of the Board in ensuring scrutiny and oversight of patient safety in maternity.

If you would like to discuss how our risk management team could help, please contact Amelia Newbold and Sian Brown.

Our fortnightly Shared Insights forum runs sessions focused on maternity specific issues to facilitate the sharing of knowledge, experiences and good practice across the health sector. You can access the key learning from previous Shared Insights sessions on the Shared Insights Hub and this includes resources focussed on the Key themes arising from obstetric claims and inquests.

To find out about our next event or register to join the Shared insights Forum contact Nicola Evans and Damian Whitlam.

Our Early Maternity Team focuses primarily on supporting the work carried out by NHS Resolution’s Early Notification Team, aimed at improving safety in maternity care through the early investigation of maternity incidents where babies are born with a potentially severe brain injury. They also help Trusts with investigations into cases where babies have died, many of which result in inquests; or where women have suffered severe injuries as a result of childbirth.

What is NHS Resolution’s Early Notification Scheme?

The Early Notification Scheme is a national programme run by NHS Resolution allowing for the early reporting and investigation of cases in order to provide families with early explanations of incidents, fair resolution and highlighting lessons that can be learned. It reflects the Government’s goal of halving the rates of stillbirth, neonatal death and brain injuries associated with obstetric delivery.

Why is this scheme so important?

Historically, resolution of claims relating to birth injury often took a significant time because of the nature of the investigations needed to determine the cause and extent of injury prior to a claimant bringing a claim. This meant that families could be left without support during the early crucial years and made investigation of such incidents difficult, as staff may have moved away or memories may have faded. The introduction of the scheme has led to early admissions of liability, where appropriate, within 18 months of the birth, and enabled support to be provided to families when they need it the most. This unique model can be used to help drive early resolution and costs savings as well as the promotion of full and open conversations with patients and their families about the care provided.

Contact Sian Brown, Kelly Buckley or Rachael Morris for more information.

  • NHS Resolution’s purpose “to resolve concerns, share learning for improvement and preserve resources for patient care” underpins each maternity claim we deal with.

  • In 2017, delivering fair resolution and learning from harm was the headline of NHS Resolution’s 5-year strategic plan. Along with the NHS Resolution’s Early Notification scheme (an innovative national programme for improving maternity care), early mediation is a key part of NHS Resolution’s plan to go ‘upstream’ and get closer to the index events to reduce claimant solicitors spiralling costs and move to a patient centred approach. Being at the forefront of this work (early maternity and mediation), we are uniquely able to influence best practice and share learning which will result in better outcomes for patients and Trusts.

  • Our team purpose is to provide expertise to the NHS to resolve concerns fairly, share learning for improvement and preserve resources for patient care.

  • Mediation and ADR is hugely important for NHS Resolution and NHS Trusts as it offers a unique opportunity for the relationship between a healthcare provider and a patient to be repaired; reduces Trust input if a case can be resolved quicker and reduces the impact on the ‘second victim’ (i.e. the profound impact of a clinical negligence claim on clinicians who Trusts need to retain). We therefore work closely with Trusts and support them through the mediation process such as with the provision of our ‘Mediation Memo’ – a clinicians guide to attending a mediation.

  • Within our Early Maternity team, Kelly Buckley, Partner is the department’s ‘mediation champion’ and our team are experienced in resolving the most complex and high profile disputes at mediation (including mediating claims within the Early Notification scheme). In all our early maternity work we do, we are advocates for empathetic and holistic resolution and resolve patients’ disputes fairly, efficiently and with integrity, putting the injured patient at the heart of the work we do.

  • As the courts push more pressure out of the system into private dispute resolution, there will be an increased demand for mediation. By collaborating together, we support further upstream collaboration between NHS Trusts and families; can carry out medical mediations and work with NHS Trusts to improve the patient complaint journey.

Contact Sian Brown, Kelly Buckley or Rachael Morris for more information.

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