An investigation by the HSJ’s Shaun Lintern, also reported in the Nursing Times, has found that many babies are dying at birth as the result of a simple mistake: a failure to correctly read the CTG trace, which monitors the baby’s heart rate:
“Data from NHS Resolution – formally the NHS Litigation Authority – shows there were almost 300 clinical negligence claims between 2011 and 2016 where the primary cause of the injury was a failure to respond to an abnormal foetal heart rate.”
There have been recent well-publicised cases, he notes, where a failure to read the trace correctly resulted in tragedy: in February, for example, coroner David Hinchliffe said of baby Maxim Karpovich, who died in 2015:
“It was apparent that the midwives involved with Maxim’s birth and the junior obstetrician appeared not to understand that the CTG trace was abnormal on several occasions.
“This inquest and many previously have caused me to note that midwives and obstetricians lack the core skills to interpret CTG tracings.”
It’s easy at this point to blame the shortage of midwives, which is putting a lot of midwives under pressure – and indeed the Royal College of Midwives (RCM) spokesperson quoted in the piece does just that. She also blames outdated equipment and the increasing complexity of birth.
The Royal College of Obstetricians and Gynaecologists (RCOG) spokesperson, on the other hand, says that errors could be reduced with a focus on multidisciplinary training:
“There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery.”
In hospitals, safety is paramount. The death of a baby should be an exceptional circumstance, and when it happens, staff should work together to review why it happened and what can be done to stop it happening again. This is what happens in organisations that have a culture of safety. The fact that in so many NHS hospitals this doesn’t happen is shocking.
Lintern goes on to mention Barking, Havering and Redbridge University Hospitals NHS Trust, which set out to tackle its rate of CTG errors. It had found that 75% of maternity “incidents” included some form of CTG error in 2015-16, but the trust had invested in staff training, equipment and an improvement in culture. In the past 11 months the trust hasn’t had a single CTG error.
According to the trust’s director of midwifery, Wendy Matthews:
“We have put in place quite a rigorous process. We’ve developed a culture of quality and safety and learning from errors which is very much about the multi-disciplinary team.”
This is a remarkable achievement. Yet it doesn’t sound as if there was a magic solution to the problem – simply that the trust approached the problem sensibly by training staff to read the CTG correctly, buying more effective equipment and working together to learn from mistakes.
In an ideal world, what would happen next is that every other maternity unit in the country would look at what Barking, Havering and Redbridge did and copy its example. This would save the NHS hundreds of millions of pounds a year in litigation – and more importantly, save the lives of hundreds of babies who die needlessly at birth.