NHS Resolution: Early Notification scheme progress report
25th September 2019
NHS Resolution has today published its Progress Report on the Early Notification scheme (EN scheme). The report looks at the effectiveness of the scheme since it was established in April 2017 and makes recommendations for the future.
The EN scheme is a national programme which was set up to provide a vehicle for the early reporting to NHS Resolution of infants born with a potential severe brain injury following term labour. The aims of the scheme are to support the government priorities of halving the rates of still birth, neonatal death and brain injury, and improving safety in maternity care. In addition the scheme aims to respond to the needs of families where clinical negligence is identified, including making early admissions of liability where appropriate. The scheme also recognises the importance of supporting NHS staff, limiting the time taken to investigate these matters and quickly sharing any potential learning.
The report advises that in April 2017 to March 2018 746 cases reported to the scheme were cross referenced against the National Neonatal Research Database. To date 24 families have received an admission of liability, formal apology and in some cases financial assistance.
The report covers the development and progress of the scheme and gives an overview of cases from 1 April 2017 to 31 March 2018.
The report is aimed at multiple levels, including staff and clinical teams, and Trust Boards. Through the scheme, families with a baby affected by a severe brain injury due to substandard care can receive significantly earlier answers and avoid full court proceedings. Timely compensation is provided to families and staff are better supported.
The report identifies a number of clinical issues identified in an analysis of a sample of cases:
- Issues with fetal monitoring were a leading contributory factor in 70% of cases. A delay in acting on a pathological CTG was the most common factor where two or more factors were identified.
- Impacted fetal head and/or difficult delivery of the head at caesarean section was a contributory factor in 9% of cases.
- Concurrent maternal medical emergencies in labour occurred in 6% of cases.
- Immediate neonatal care and resuscitation affected 32 % of cases in the sample.
The report makes 6 key recommendations which prioritise further research and safety initiatives. The recommendations are:
- All families whose baby meets the Early Notification criteria should be offered a full and open conversation about their care. This includes an apology in accordance with the statutory duty of candour, a description of the intended investigation process and options for their involvement in investigations.
- An independent package of support should be offered to all NHS staff and in particular to those involved in incidents.
- There is an urgent need for an evidence-based, standardised approach to fetal monitoring in England. Research in this area should be prioritised.
- There needs to be increased awareness of impacted fetal head, difficult delivery of fetal head and techniques required for care. Research is also required to understand the prevalence, causes and management alongside effective training in management techniques.
- Work needs to be done with existing national programmes to improve the detection of maternal deterioration in labour, including monitoring and the implementation of evidence-based guidance. This includes prioritising research into the prevalence and cause of significant hyponatraemia in labouring mothers.
- There needs to be increased awareness of the importance of high-quality resuscitation and immediate neonatal care on outcomes for newborn babies, emphasising the importance of collaboration between all professional teams.
The full report can be accessed here.
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