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Tragic baby monitoring issues in Shrewsbury and Telford but this issue is national

As specialists in the field of medical errors, the clinical negligence team at JMW has a bird’s eye view of the patient safety issues that emerge as recurrent themes.

We unfortunately see the same mistakes happening over and over again in different NHS trusts nationally. Despite often very significant injury being caused to patients and millions being paid out in compensation it is often unclear whether the NHS recognises the issue and has a plan to address it

As we deal with many brain injury cases at JMW, one such issue we are aware of is poor monitoring of babies’ heart rates during labour. This can lead to signs of distress being missed and the baby’s delivery being delayed causing their oxygen supply to be severely compromised and sadly for their brain to be damaged. This can cause permanent cerebral palsy, and all the life-long physical and mental disabilities this brings, and it can also cause the baby to die.

It’s an issue that has hit the headlines in the last few weeks due to a maternity trust being put under investigation after seven baby deaths between 2014 and 2016, five of which have been linked to poor heart rate monitoring.

Trust warned 

Worryingly the trust was warned there were issues with its fetal heart rate monitoring back in 2007 by the NHS regulator at the time (BBC). Health secretary Jeremy Hunt has now ordered an investigation into the deaths. This may provide answers for the families affected by such a devastating loss and ensue lessons are learned at this trust.

However even more valuable would be to investigate why the NHS as a whole cannot get to grips with this issue. The Shrewsbury and Telford Trust had a high number of baby deaths linked to this issue in a short time frame, ringing alarm bells. However it is far from the only trust that has made mistakes in the area of fetal heart rate monitoring and a significant number of the cerebral palsy cases the team at JMW is handling are linked to this issue.

The errors we see can concern a failure to carry out monitoring adequately, or at all, misinterpretation of the CTG trace (which provides a graphical reading of the baby’s heart rate) or monitoring the mother’s heart rate by mistake and being wrongly reassured that all is well.

Issue is a national one

Both doctors and midwives use CTG fetal heart rate monitors regularly for a variety of reasons. It may be because the mother has reported reduced movements, pain or bleeding, drugs for pain relief or induction of labour have been provided, the pregnancy is high-risk or for any other reason the baby may require an extra level of monitoring. However decades after it was introduced into the NHS it remains an area where many mistakes are made with clearly catastrophic consequences.

Children and families are being robbed of their lives due to this issue so Jeremy Hunt should take a broader approach to his investigation and look at the picture nationally to reveal why mistakes are being made and what needs to be done to improve care in this area.

 

 

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