Midwives failing to check babies’ heart rates during labour is the biggest cause of birth blunders in NHS, an investigation has found.
An analysis of “devastating” cases which ended in brain injury found that seven in ten involved a failure to properly monitor the foetus.
And in almost two thirds of such births, at least two errors were made, with repeated missed chances to prevent death and avoidable injuries.
The research, which examined 96 births, follows official figures which show that almost £5bn of negligence claims were lodged against the NHS in 2018/19.
Half of this – almost £2.5bn – involved claims relating to alleged blunders in maternity.
The investigation also calls for urgent changes to ensure babies were properly monitored during labour.
Incompetence in a state organisation though…..
Some personal experience on my part: my first child had the cord wrapped around his neck, so his heart rate dropped whenever there was a contraction. But the midwife and consultant were very aware.
My second didn’t have the same problem, but there were others. Frankly, it’s down to the midwife. Some are very good, others just don’t give a toss.
And, of course, being public sector workers, it’s impossible to weed out the ones who don’t give a shit…
@JuliaM: indeed. Where else are we going to go? Most of us couldn’t afford private.
For years people have been pointing out that medicine really ought to be looking at how aviation massively reduced its accident rate from the middle of the last century. Proper investigation of all incidents that could have led to death is one of aviation’s main tools, but it only works if procedures are changed in response to findings of the investigations. One wonders whether this report will have much affect.
Tom J: so when they say, “Lessons have been learned” we shouldn’t fire all those concerned with confiscation of pensions. The NHS is so protective of its employees, only Ecksian solutions might tip the balance in favour of patients.
TomJ,
It won’t have much effect at all. The people in charge of hospitals don’t personally pay this compensation. They have little incentive to improve processes unless told to.
You have to have hospitals owned by capitalists who don’t want to get poor because people go elsewhere.
“The people in charge of hospitals don’t personally pay this compensation.”
We don’t know that the hospitals do, either.
‘official figures which show that almost £5bn of negligence claims were lodged against the NHS’
“Claims lodged” and not what was actually paid out. May have been less than 10% of lodged.
So in spite of the big number, £5bn, there may be little actual savings to be had by doing better.
And the unstated goal of the article might be to attack midwives. Some people think they have no place in a hospital.
“Midwives cost NHS £5bn a year” is how to read the story.
@TomJ
As I understand it, one of the big things with aircraft safety improvements was a change from adversarial investigations “someone has died – who do we blame?” to an cooperative approach that tries to be much more “someone has died. How can we ensure no-one else does from the same cause?”.
Even if the answer to “why did someone die?” boils down to “Someone else was a careless idiot”, you look at the events surrounding this, and see if the problem was employing idiots without sufficient vetting, or how they were trained, or if their workload was excessive at the point where everything went wrong.
I get the impression that with medical cases, it’s often still the blame game being played.
Its also interesting that the vast majority of people working in midwifery are female. Thus putting the lie to the concept that women are somehow more empathetic and customer oriented and that female dominated organisations would be far superior to male dominated ones.
Of 96 births half were bungled. And this is “urgent”? How many births are there per year?
A quick gurgle gives 670,000 in 2016, so 48 bungled births is 0.007%. And this demands “urgent” action.
http://www.ihi.org/communities/blogs/_layouts/15/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=268
shocking how deathrates collapsed as hospitals put basic checks in place
“Of 96 births half were bungled. And this is “urgent”? How many births are there per year?
A quick gurgle gives 670,000 in 2016, so 48 bungled births is 0.007%. And this demands “urgent” action.”
No, they examined 96 cases specific cases of birth brain injury of which 70% involved failure to monitor heart rates, and 66% contained 2 or more significant errors. 96 is not the total number of births that result in brain injury, that figure is far higher – in 2015 655 babies suffered brain injury during birth, and a further 266 died either during or immediately after birth. (Figures here: https://www.teeslaw.com/article/birth-injury-statistics)
So if a representative sample of brain damaged babies shows that 70% had significant medical errors leading to those injuries, one could conclude that potentially around 650 babies per year are dying in child birth, or being born brain damaged due to negligence by the NHS.
I’d say that very much requires urgent attention.
Was taught that it’s a basic concept that separating the investigation from the disciplinary/punishment leads to a better outcome in understanding what went wrong and how to fix it which is the main purpose. Blaming people never solves anything, ask someone to explain what they did is a better question than tell me what you did wrong.
Subsequent action against people or organisations is a sideshow and while it can use evidence from the investigation isn’t the purpose of the investigation
Ljh,
I have in the back of my mind that you are/were a GP? If that’s correct it makes this statement even more telling:
Tom J: so when they say, “Lessons have been learned” we shouldn’t fire all those concerned with confiscation of pensions. The NHS is so protective of its employees, only Ecksian solutions might tip the balance in favour of patients.
Anyway, my point is that “lessons have been learned” is usually bollocks. What they really mean is that lessons have been identified. They’ve only been learned when the organisation/institution has been through a major training programme that has included changes to process and procedures and behavioural change as part of that training.
Lessons have only been learned when they can demonstrate that whatever happened is no longer happening because of the training and changes and not because of good luck.
As I understand it, one of the big things with aircraft safety improvements was a change from adversarial investigations “someone has died – who do we blame?” to an cooperative approach that tries to be much more “someone has died. How can we ensure no-one else does from the same cause?”.
Even if the answer to “why did someone die?” boils down to “Someone else was a careless idiot”, you look at the events surrounding this, and see if the problem was employing idiots without sufficient vetting, or how they were trained, or if their workload was excessive at the point where everything went wrong.
I get the impression that with medical cases, it’s often still the blame game being played.
IANAL and m’Lud may be able to explain this better based on a the recent case, but here goes:
(This also applies to the Marine AIB)
It was the case that the reports and their evidence collected were deemed hearsay and not admissible but that has now been overturned and, from my understanding, some of the evidence from expert witnesses can now be used. Plod had to do a separate independent investigation.
However this has been overturned (see the link above) in the case of expert witnesses (from my reading). What effect that will have long term is anyone’s guess, when a pilot crashed killing an onlooker and the pilot survived
How that changes investigations and their ability to get to the bottom of accidents is anyone’s guess, but it probably means some of those involved are likely to be more reticent about owning up when something went wrong and they could be blamed.
However this has been overturned in the case of expert witnesses (from my reading), what effect that will have long term is anyone’s guess, when a pilot crashed killing an onlooker and the pilot survived
@BiND
Also, and possibly even more significant, there’s CHIRP (the Confidential Human Factors Incident Reporting Programme) which allows the confidential reporting of incidents that might have contributed to an accident and provides a key data set for identifying potential problem areas before an accident can occur.
A very similar accident investigation and confidential reporting system exists for marine, too.
“The medial people responsible don’t personally pay this compensation.”
The way to remedy this is they must each purchase professional liability insurance – tax deductible, but not expense claim reimbursed.
Insurers would quickly identify the incompetents and hike premiums or refuse cover
@ Pcar
No-one (at least no-one sane) will insure the NHS when its owner can change the rules retrospectively at will.
The Burmah Oil case against the government was dragged out from the time that Harold Wilson was the culprit until Harold Wilson was PM and got his party to pass a retrospective law to abolish HMG’s liability to Burmah Oil – the Opposition did not make the proper fuss because the husband of the Leader of the Opposition was a major shareholder in Burmah Oil and should have pocketed several; £millions if the law had been obeyed.
So insurers know that a Labour government will welch on its liabilities and insuring a NHS employee is insane
Chris,
Yes, CHIRP works well. I’ve read of a few leisure sailors using it and they were impressed how seriously they were taken.
@john77 September 26, 2019 at 10:47 pm
Dentists must buy their own professional liability insurance as must Dental Nurses and Hygienists. Fail to do so and GDC strike off.
Insurer is insuring the person, not the organisation, hence MDDUS cover NHS employees too. NHS’s own indemnity cover should be ended.