The Royal College of Obstetricians and Gynaecologists (RCOG) welcomes the report on clinical negligence claims published by the NHS Litigation Authority today (26 October 2012).
This report analyses the costs to the NHS of litigation in maternity services over a ten-year period between 2000 and 2010. In that time, there were 5,087 maternity claims costing a total of £3.1bn from a cohort of approximately 5.5 million births. This constitutes less than 1 in 1000 births ending in litigation.
The most common causes of claims were for:
- Management of labour
- Caesarean section
- Cerebral palsy
Four risk areas were identified for further review and analysis. These were: antenatal ultrasound investigations, cardiotocograph intepretation in labour, perineal trauma and uterine rupture. In some of the categories, multi-factorial contributory factors were found. Risk management recommendations have been developed for each of these categories.
This report provides NHS boards and healthcare professionals with good data on the situations leading up to claims from a risk management perspective and the areas where compliance is fundamental to providing high quality care.
David Richmond, RCOG Vice President (Clinical Quality) said,
“This report has defined why problems occur and provides us with valuable information so that maternity services can put in place robust monitoring and risk identification systems to prevent them from recurring.
“Our most recent reports High Quality Women’s Health Care* and Tomorrow’s Specialist* make a strong case for the NHS to move to a consultant-delivered service so that trainee doctors receive adequate support and women have access to qualified specialists throughout the day and night. Alongside the recommendations from the NHS LA, we now have good information on how we can learn from past mistakes so that new ones can be prevented.
“NICE and RCOG produce clinical guidelines covering all aspects of pregnancy and childbirth. The guidance and protocols must be readily accessible to all staff. The recommendations should be implemented, audited and the outcomes measured in a timely manner to identify trends and manage risk appropriately. A multidisciplinary approach to care must be adopted so that best practice is instigated and action taken. Feedback of good and bad outcomes must be shared and lessons learned.
“There are over 720,000 live births in England and Wales each year. In most cases, it is a normal physiological process but many mothers and babies require medical attendance during and after delivery. As a true 24/7 emergency discipline, surely it is time to recognise that fully trained doctors must be available on site throughout the day and night. This supports earlier recommendations from RCOG reports* of the need for greater consultant presence on the labour ward. Parallel increases in midwifery numbers at the appropriate grade are also needed. The cost of fully staffing the units in England and Wales would be around half the cost of litigation per year and would contribute to reducing the claims considerably.
“Some of the report findings recommend better training and learning for all professionals including trainee doctors and midwives. This could be achieved more uniformly with better staffing, using every opportunity for training and supervision throughout the 24 hour day, seven days per week.
“The NHS LA report is staggering in its stark facts and the reality of the enormous costs of maternity litigation. Hidden behind the financial burden are countless stories of tragedy to individuals and families, which are not included in this report. This is a serious wake-up call to all with responsibilities in providing maternity care, whether as providers, commissioners or regulators. Urgent action is needed to further improve the safety of clinical services for women and their babies.”
Moving forward, the RCOG believes that:
- A clinical database is urgently needed to run in parallel with that of the NHS LA, akin to the Confidential Enquiries into maternal death, which have been very successful in improving outcomes and reducing deaths by highlighting deficiencies in care. This transparent national report of maternity mortality and morbidity outcomes, appropriately case mix adjusted, should be produced within 12 months of the index period.
- There is the need to audit guideline implementation and assess the role of failure of training and guideline use in claims.
- Analysis of litigation claims needs to feedback to the professions, Trusts, hospitals and birthing units in a timely manner so that lessons can be learnt and action taken.
- Urgent government action is needed to improve staffing ratios, perhaps linking with the insurance and legal sectors for funding. The present tariff of maternity care is unsustainable.
- There is the need to build on RCOG guidelines and training in drills and skills.
- There is the need to increase investment in research and innovation and harness new technologies, eg. electronic fetal monitoring, to improve outcomes.
The RCOG welcomes this report and will be delighted to contribute to working with the NHS LA, Government and other healthcare colleagues to address the key findings and develop a range of meaningful actions.
RCOG/RCM/RCoA/RCPCH (2007) Safer Childbirth. Minimum Standards for the Organisation and Delivery of Care in Labour
RCOG Expert Advisory Group Report (2011) High Quality Women’s Health Care
RCOG Working Party Report (2012) Tomorrow’s Specialist
To view the NHS LA report, click here.
Through the years, the RCOG has developed several tools such as the Maternity Dashboard, guidance on improving patient handover and developing standards in maternity and in gynaecological care.
The RCOG’s e-learning for fetal heart monitoring was developed with other professionals to enable better detection during childbirth of babies who may be in distress.