Last month I wrote a series of posts about the decision by the Royal College of Midwives to shutter its Campaign for Normal Birth. Although the RCM leadership denied it, some going so far as to claim dead and injured babies are “fake news,” the campaign was stopped because of skyrocketing rates of maternity liability claims. Indeed nearly £2bn was paid out in compensation in the past year alone.
A just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data, investigates those claims. The report is detailed, comprehensive, and contains multiple valuable recommendations. It also identifies the single most important reason why UK maternity liability claims have been skyrocketing: perinatal deaths and injuries aren’t being properly investigated.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Perinatal deaths and injuries aren’t being properly investigated.[/pullquote]
As the Executive Summary of the report notes:
The quality of root cause analysis was generally poor and focused too heavily on individuals.
Due to the poor report quality, the recommendations were unlikely to reduce the incidence of future harm.
It’s almost as if the people responsible for deadly errors don’t want to know why they happened.
The gold standard for investigating errors is Root Cause Analysis (RCA).
It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:
Determine what happened.
Determine why it happened.
Figure out what to do to reduce the likelihood that it will happen again.
Although RCA can provide information and closure for families, it’s primary purpose is to identify modifiable factors that can be improved in order to prevent future bad outcome.
As the NHS Report notes:
A RCA should be logical, fair, open and adopt a just, or fair blame, culture, as it is often a system failure rather than an error by an individual that is at fault. It is therefore vital that a RCA looks at the wider environmental and organisational factors, often referred to as latent conditions, that allowed the error to occur.
In other words, rather than seek to blame individual bad actors, an RCA looks for systemic failures. In contrast, internal investigations of NHS maternal liability claims focused on assigning blame, not the root causes.
Looking at the root causes within the reports, it appeared that the question of why the incident happened, or was allowed to happen, is often missing…
It’s almost as if the people responsible for deadly errors don’t want to know why they happened.
The root causes identified in the reviewed cases included:
The most common contributing factors were poor individual skill level and failure to communicate with others.
Why was the pathological CTG managed incorrectly? What went wrong with the undiagnosed breech and why did that result in CP? Why was the scan incorrect? Was it inadequate training, a faulty machine, that the operator was distracted? Why did a woman with a concealed abruption have a baby born with CP, remembering that these 50 claims are due to admitted clinical negligence, so what went wrong with her care?
No attempt was made to address these critical questions.
It’s almost as if the people responsible for deadly errors don’t want to know why they happened.
This is not new information:
The Kirkup report identified significant systematic and organisational failures which the Morecambe Bay hospitals own SI investigations and RCA process missed, as they were “rudimentary, over protective of staff and failed to identify underlying problems…”
The RCOG EBC project identified that 25% of local reviews did not contain sufficient information to allow the care to be classified. Of those reviews that were of sufficient quality, just over 60% of investigations used a RCA methodology, while 21% contained no actions or recommendations and 23% recommended actions focusing solely on individuals.
The CQC report demonstrated a worse picture within acute trusts. Only 8% of reports demonstrated evidence that a clearly structured methodology was used, which would identify the key issues, contributing factors, system issues and causal factors that led to the incident…
As the parent of an injured baby explained:
It feels like the priority of the serious incident process is damage limitation rather than learning from mistakes. What makes this even worse is the lack of learning both by the trust and the wider NHS from what happened. The problem with the quality of the report… is that its purpose was not to blame individuals and was to nd a root cause [but] it stopped at individual mistakes and not once did it ask why people made these mistakes.
“The frustration from our case is that if a proper root cause had been found, such as training not being given or procedures not being known then it would not just stop similar cases to ours but could reduce serious incidents across the trust.
It’s almost as if the people responsible for deadly errors don’t want to know why they happened.
If there is no serious attempt to identify modifiable systemic failures, the same failures will occur over and over again. And that is precisely what has occurred.
It appears that the individuals involved were expected to follow guidelines that were in place the next time a similar incident occurred, without identifying why they were not followed in this instance. Identifying an issue with the guidelines that could be changed may result in better care for someone else.
This is not new information, either.
The findings of this review are very similar to those identified within the RCOG EBC programme, that only 56% of the investigations they analysed had actions or recommendations that took a systemic approach, 23% focused solely on individuals, often to attend training, and 21% contained no actions or recommendations.
The CQC report on SI investigations also highlighted the same problem. They found that “too many reports concluded that the actions of staff were the key causes of the incident” and many investigations focused their recommendations on staff failing to “follow trust policy and procedures.” Only 35% of investigations had recommendations that could reduce the risk of recurrence and many focused on reminding staff be more vigilant or to follow guidelines.
It’s almost as if the people responsible for deadly errors don’t want to know why they happened.
The Report makes a critical recommendation:
In line with the Kirkup and RCOG Each Baby Counts reports, all cases of potential severe brain injury, intrapartum stillbirth and early neonatal death should be subject to an external or independent peer review.
If those responsible for understanding why deadly errors occur either can’t or won’t identify systemic causes, review should be undertaken by external, independent panels.
Unless and until that happens, babies will continue to be injured and will die and the NHS will continue to bleed money on liability claims for preventable errors.
