APPENDIX 44
Memorandum by Action for Victims of Medical
Accidents (MS 53)
INTRODUCTION
1.1 Action for Victims of Medical Accidents
(AVMA) was established in 1982 to work on behalf of the victims
of medical accidents. AVMA's work covers three main areas: to
provide advice and support to medical accidents victims and their
advisors; to campaign to ensure that the needs of injured patients
are addressed including where appropriate, access to a fair system
of compensation; and to work with healthcare professionals and
other agencies to reduce the number of avoidable medical accidents.
1.2 Enquiries relating to maternity services
represents the highest proportion of enquiries that AVMA deals
with. This is both through AVMA's direct services to patients
and through our Lawyers Resource Service, an advice and information
service for clinical negligence lawyers.
1.3 AVMA's role in advising patients has
given us a particular insight into the problems associated with
failures in our maternity services from the patient's perspective.
1.4 The rise in legal claims relating to
obstetric care is often blamed on unrealistic parental expectation
ie the right to a perfect baby. However, the reality is that only
a relatively small proportion of avoidable adverse outcomes in
obstetric care result in a claim for compensation. The picture
is somewhat distorted because cerebral palsy claims take up a
disproportionate amount of the clinical negligence budget because
of the high costs associated with these claims. Obstetric claims
currently represent one in five of cases dealt with by the NHS
Litigation Authority and 80% of the costs of all claims. However,
it is important not to concentrate on the issue of litigation
because this distorts what is the real issue, that of the frequency
of avoidable adverse outcomes and the harm being done to mothers
and their babies. Historically we have had a situation where the
issue of medical accidents was perceived not so much from the
perspective that too many mistakes were taking place but that
too many patients were litigating. This meant that rather than
focusing on reducing the number of accidents, the emphasis was
on reducing the amount of litigation. When the concept of risk
management was first introduced, this was often interpreted as
litigation management and less that of reducing the risks of harm
to patients. This is something that we need to move away from
to enable everyone to concentrate on reducing accidents by introducing
a more systematic approach to identifying and responding to adverse
events. This is something the NHS has been very poor at doing
up until the present time.
1.5 AVMA is particularly concerned that
the same causative factors which have resulted in a poor outcome
or injury to mother or baby continue to be seen. This is despite
the fact that this is one area of medicine that has been subject
to two separate confidential inquiry processes, the Confidential
Inquiry into Stillbirths and Deaths in Infancy (CESDI, established
1992) and the Confidential Inquiry into Maternal Deaths (CEMD,
established 1952), and well before the introduction of bodies
such as the Commission for Health Improvement and other systems
of scrutiny. These reports have continued to highlight the causes
of adverse outcomes in maternity care but progress has been very
slow in translating these lessons into practice. It is unclear
whether this is primarily a resources issue or a more general
failure to overcome the complacency that has been associated with
medical accidents.
1.6 Similarly, the fact that the same maternity
units have been known to crop up in a disproportionate number
of cases also raises concerns about how and why that situation
is being allowed to continue and why there are not more effective
systems in place to react more immediately to unsafe practices
and procedures.
1.7 No one should underestimate the human
cost of adverse outcomes in obstetric care. The death of a healthy
baby or a lifetime of caring for a disabled child who should have
been healthy is a devastating outcome from what should have been
a happy event. The families concerned have every right to question
how this could be allowed to happen and why. Both the CESDI reports
and the EuroNatal Study—European comparisons of perinatal
care—identify that suboptimal care is responsible or contributes
to substantial numbers of avoidable stillbirths and neonatal deaths.
At a conservative estimate, we are looking at over 800 potentially
avoidable stillbirths a year. What is of particular concern is
that many stillbirths classified as "unexplained" by
healthcare providers, would have been explained if a proper analysis
and investigation had been undertaken at the time to look at the
potential causative factors. This is a critical issue because
we cannot begin to address failures in service provision if we
are not identifying and responding to adverse incidents and thereby
learning from what has happened.
1.8 It should also not be forgotten that
healthcare professionals involved in medical accidents are often
left in an invidious position. The failure to openly acknowledge
and investigate adverse events, means that healthcare professionals
may not have access to effective debriefing and support systems
and the means to put their actions into context. This is perhaps
particularly true in the case of maternity services, where usually
a good outcome is to be anticipated. Until we can meet the needs
of healthcare professionals, it is unrealistic to expect them
to meet the needs of their patients.
1.9 By the nature of AVMA's work, this response
will concentrate on AVMA's experience of maternity services from
the perspective of the parents who believe they have been let
down by the service leading to an injury to either the mother
or the baby.
ADVERSE OUTCOMES
IN MATERNITY
CARE
2.1 There is perhaps a fine line between
avoiding over-medicalisation of normal childbirth whilst retaining
the skills and knowledge to detect and respond to the abnormal.
There is considerable concern expressed over what are perceived
as unnecessary interventions including the increasing number of
deliveries by caesarean section and yet many of the cases that
AVMA sees relate to a failure to intervene when intervention is
required. Some would argue that less intervention would be required
if maternity services were more patient-centred and better equipped
to respond to the needs of pregnant women. For example, through
providing continuity of care, avoiding interventions such as induction
of labour when not necessary, improving the quality of training
for maternity staff etc.
2.2 AVMA receives a wide range of maternity
related cases, but many follow a familiar pattern. These include
cases involving:
— Antenatal care eg antenatal screening,
the identification of risk factors, intrauterine growth retardation,
treatment of pre-eclampsia, care of the diabetic mother, diagnosis
of rare conditions of pregnancy.
— Intrapartum care eg the interpretation
of electronic fetal monitoring, diagnosis and management of shoulder
dystocia, haemorrhage, management of multiple births, breech deliveries,
erbs palsy, maternal injuries, use of forceps.
— Induction and augmentation of labour
and its complications.
— Complications of caesarean sections
including injury to mother and/or fetus and vaginal delivery after
caesarean section.
— Management of premature labour.
— Neonatal care eg hypoglycaemia, infection.
— Specific problems associated with
home births and independent/private healthcare.
2.1 This list is not exhaustive and it is
not appropriate to cover all of these issues within the remit
of this paper but we would like to highlight certain of these
to illustrate why it its so important that a more systematic approach
is developed for identifying and learning from mistakes.
INDUCTION AND
AUGMENTATION OF
LABOUR
2.4 The use of oxytocics (eg prostaglandins
and syntocinon) in the induction and augmentation of labour has
long been a source of concern with respect to the adverse outcome
of labour. There is an apparent lack of adequate research into
the risks associated with these drugs with the result that healthcare
professionals often appear unaware of the significant potential
for harm in their use of these drugs. In turn, mothers themselves
are not warned of the potential risks which includes hyperstimulation
of the uterus, uterine rupture and fetal hypoxia as well as the
"cascade of intervention" that is often associated with
induction. These risks were exacerbated following the change
towards increasing the number of vaginal deliveries in mothers
who had had a previous caesarean section. The particular risks
in this situation were often underestimated (see below, Trial
of Labour).
2.5 AVMA has seen too many examples where
repeated attempts at induction of labour have been made involving
repeated doses of prostaglandins. A typical scenario would be
where no apparent progress is made after the first, second or
third application of prostaglandin and then the uterus suddenly
becomes hypertonic, leading to fetal compromise, hypoxia and in
some cases uterine rupture and fetal death.
2.6 More recently, the problems of underestimating
the risks associated with induction were highlighted in relation
to a trial of a relatively new prostraglandin agent, Misoprostol.
Misoprostol is known to reduce delivery time but perhaps inevitably,
also increases the risks of uterine rupture and hyperstimulation.
Some might argue that the use of such an agent is a symptom of
the "medicalisation" of labour. There is anecdotal evidence
of some disturbing issues arising out of trials of this drug in
women in the United Kingdom leading to disastrous outcomes for
mother and baby.
TRIAL OF
LABOUR
2.7 AVMA has seen many examples where a
"trial of labour" has been planned in the light of pre-existing
risk factors including diabetes, previous caesarean section, potential
cephalo-pelvic disproportion etc, but due a breakdown in communication
or a failure in management at the time of delivery, a "trial"
does not appear to have taken place, labour being allowed to continue
without cognisance of the trial or the risk factors that are present.
In some cases it appears that this is due to a failure of the
clinician to provide adequate instructions in terms of how long
the labour should be allowed to continue, the risk factors that
those attending the mother need to be aware of and the indications
for intervention.
2.8 It is important that where a trial of
labour is being embarked upon, the resources and staff are available
should intervention be required. AVMA has seen a number of examples
where a trial of labour following induction has failed and urgent
intervention is required but no theatre staff were available when
needed.
ANTENATAL CARE
2.9 AVMA sees a range of problems arising
as a result of failures in antenatal care from failure to detect
and/or respond to intrauterine growth retardation, failures in
antenatal screening for fetal abnormality, rhesus incompatibility,
management of threatened miscarriage or premature labour. Communication
is often a critical factor and again, particularly in relation
to listening to the individual mother and her concerns.
MATERNAL INJURIES
2.10 It is only in relatively recent years
that the complacency surrounding maternal injuries during delivery
has begun to be challenged. In the past, AVMA regularly received
enquiries from mothers who had been left incontinent of urine
and faeces following a difficult delivery where the problem was
either not acknowledged or little in the way of active intervention
was offered, the response being that this was an avoidable part
of bearing children. We would like to say that this is no longer
the case but AVMA is still seeing cases where there has been a
failure to acknowledge the impact of such an injury on the mother's
ability to cope physically, practically and emotionally. This
might also explain why cases involving retained vaginal swabs
are still being seen and not detected for considerable periods
of time despite the mother expressing concern that something is
wrong.
2.11 The psychological trauma associated
with childbirth has also only relatively recently been recognised.
There has been a tendency, where both mother and baby have physically
recovered, to dismiss such trauma on the basis that the mother
should be pleased that they are both healthy albeit that they
might have had a "near miss". However, where a mother
(and partner) have experienced a traumatic delivery, perhaps involving
an instrumental delivery or emergency caesarean section, this
can have a significant impact on the parents to the extent that
the mother may be unable to face a future pregnancy. Many mothers
report that as a consequence of the trauma they have been unable
to bond with their baby. It is essential that staff are alert
to the trauma that can sometimes be associated with a difficult
delivery and be able to offer the appropriate support and counselling
that may be required to help the mother (and partner) come to
terms with the experience.
2.12 Perhaps the most significant trauma
associated with childbirth is that of anaesthetic awareness, where
either an epidural or a general anaesthetic has failed during
the course of a caesarean section. This is fortunately far less
frequent than was the case some 10 to 15 years ago although cases
are still being seen, particularly in relation to failed epidurals
during caesarean section. This is again an issue of not listening
to the mother.
Independent Sector
2.13 The independent sector is not immune
to avoidable adverse outcomes in maternity care. There was considerable
disappointment that following the introduction of the Care Standards
Act 2000, the regulations governing independent healthcare, and
in particular clinical care, still failed to address in any substantial
form, the systemic failures in service provision. It is essential
that along with other areas of independent healthcare, that gaps
in the regulatory system are addressed to ensure minimum safe
standards of care.
CAUSATIVE FACTORS
FOR ADVERSE
OUTCOMES IN
MATERNITY SERVICES
3.1 In reviewing the range of maternity
cases that AVMA receives, it is possible to identify a number
of common causative factors that arise in these cases.
— Staffing and resources.
— Use and interpretation of electronic
fetal monitoring.
— Misapplication of protocols.
Communication
3.2 Communication is often quoted as a significant
factor in relation to healthcare complaints. This potentially
sounds like a relatively minor issue and there can be a tendency
to interpret it as meaning that patients have failed to understand
or listen to information that is given to them ie an issue of
"misunderstanding" rather than there actually being
a significant failure in healthcare provision. Communication is
a critical factor in adverse events generally but is also a significant
factor in obstetric accidents, particularly where there is a lack
of continuity of care.
3.3 Communication skills training has in
the past tended to concentrate far too much on how to convey information
and far too little on how to actively listen to patients. Failing
to listen to what mothers are telling healthcare professionals
is a critical factor in a significant number of cases that come
to AVMA. In theory, if healthcare is to become more patient centred,
then greater emphasis should be given to listening to the individual
patient and their needs rather than trying to make the patient
fit the needs of the service.
3.4 With the increasing use of overseas
recruitment, it is also important to ensure that effective communication
between professionals and with parents is not further undermined
by language difficulties.
3.5 A number of examples have been set out
below to illustrate the importance of communication.
Example A
This was Mrs B second pregnancy. In her third
trimester she began to develop a number of apparently non-specific
symptoms including extreme tiredness which led to her having to
spend long periods in bed where ultimately, she was effectively
bedridden. Over a period of three weeks she was seen by a number
of GPs and midwives attached to her GP practice. Her condition
was put down to pregnancy and having an active toddler. She rarely
saw the same practitioner on more than one occasion so that no
one individual developed a clear picture of her evolving symptoms.
On the final occasion that she was seen by a GP, it was only
on the mother's insistence that something was wrong, that it was
reluctantly suggested that if she was that concerned, she should
attend the local hospital for fetal well being to be checked.
Her family took her to the local hospital where acute fatty liver
of pregnancy was immediately diagnosed and "blue-light"
referral to a specialist liver unit arranged. Unfortunately, the
baby had already died within the previous twenty-four hours. Although
acute fatty liver of pregnancy is a rare condition, if the mother
and her family had been listened to and their concerns taken on
board, an earlier referral to hospital could well have resulted
in a different outcome.
Example B
A mother and her husband attended her local maternity
unit believing herself to be in labour and concerned that something
was not right. This was her first baby. The unit was very busy.
Without performing an examination or making a record of the visit,
a midwife advised the mother that she had come in too early and
should return home until labour was more established. This the
mother did but she and her husband became increasingly concerned
about her condition and telephoned the unit for advice. They were
told to wait at home. The couple became more anxious and returned
to the hospital and saw a different midwife. Again they were advised
to return home which they did. A short while later they telephoned
the hospital but were still advised to remain at home. After a
further telephone call, the couple decided to return to hospital
of their own accord. On this occasion the mother was examined
and it was diagnosed that the baby had died.
Staffing
3.6 A significant proportion of midwives
would probably support the view that resources and in particular,
staffing levels, prevents them from providing the sort of care
that they believe is both safe and meets the needs of mother and
baby. Midwives are often in the firing line when it comes to adverse
outcomes in maternity care and yet the midwife may have been working
in an environment that meant that a disaster was waiting to happen.
3.7 It is essential that we move towards
a twenty-four hour service as opposed to a nine to five, Monday
to Friday service. It is of no surprise when dealing with enquiries
to find that a serious adverse outcome has taken place either
"out of hours", on a bank holiday or coinciding with
the intake of new junior doctors.
3.8 Minimum safe staffing levels across
all maternity services need to be set and to be enforceable. There
needs to be an effective on-call system to cope with busy periods—a
department being over-stretched being an explanation often given
to parents when something has gone wrong.
3.9 Minimum standards for consultant and
senior midwife cover need to be established to ensure that in
emergency situations, or where intervention is required, there
are experienced members of the team available. Senior cover at
night is particularly important. The CESDI reports have frequently
identified the lack of consultant cover as a significant factor
in avoidable stillbirths. It is notable that the difficulty is
not so much that of identifying there is a problem requiring intervention
as that of there being someone available of sufficient seniority
and experience to make the decision about what needs to be done
and to act upon that decision.
Use and Interpetation of Electronic Fetal Monitoring
3.10 If used correctly, electronic fetal
monitoring (EFM) or cardiotachographic (CTG) monitoring can be
a useful adjunct to the management of labour. However, there are
a number of risks associated with the use of electronic fetal
monitoring. Firstly, there is a temptation to use CTG monitoring
as a "proxy midwife", CTG monitoring replacing continuous
care by a midwife, particularly when the maternity unit is under
pressure. The fact that the well-being of the fetus is being "monitored"
by a CTG machine can give a false sense of security in that there
is some reassurance that labour is being supervised, albeit electronically.
3.11 Secondly, the failure to correctly
interpret CTG tracings continues to be a feature in a substantial
proportion of cases involving fetal hypoxia, cerebral palsy and
stillbirths. CTG monitoring is only as good as the healthcare
professional interpreting the traces. Interpretation of CTG traces
is somewhat more complex than simply identifying particular patterns
on the trace; these have to be interpreted within the overall
context of such issues as previous obstetric history, risk factors,
maternal well-being, stage of labour, results of other procedures
such as fetal blood sampling etc. Whilst there has been some considerable
improvement in training in the interpretation of CTG traces, the
failure to correctly use and interpret electronic fetal monitoring
is still a major cause for concern. This has continued to be highlighted
in the reports of the Confidential Enquiry into Stillbirths and
Deaths in Infancy (CESDI). There are still examples where healthcare
professionals have interpreted poor CTG traces as a machine fault
rather than a hypoxic infant and it is only after the machine
has been changed several times that this is recognised. One might
question why there is not greater availability of more advanced
machines which are capable of identifying when clinical input
is required to check the status of mother and baby.
3.12 An additional risk associated with
electronic fetal monitoring is that of unnecessary intervention
but this largely relates to the failure to correctly interpret
the CTG trace in the context of that particular mother and baby.
Training
3.13 Evidence of inadequate training and
supervision being a causative factor in adverse outcomes is often
apparent in cases that are seen by AVMA. Some aspects of training
are dealt with under separate sections, most notable, that of
electronic fetal monitoring, the use and risks of protocols and
communications training.
3.14 All maternity staff should have regular
updating of skills which should include feedback from specific
adverse incidents ie learning from mistakes.
3.15 Learning about medical accidents, the
causes and consequences, should be a core part of all clinical
training. This is important because it will aid the process of
creating a more open culture where mistakes can be acknowledged
and dealt with in a more systematic way. This in turn will help
ensure lessons can be learnt and services improved. It is to be
hoped that through a combination of the work of CESDI, CEMD, the
National Patient Safety Agency, the Commission for Health Improvement
and the Royal Colleges, there will be far greater dissemination
of information between healthcare providers in relation to adverse
outcomes in maternity services. In the meantime, healthcare providers
need to much better systems for identifying and investigating
adverse outcomes within their service. At the present time, there
is still a considerable amount of work to do and the investigation
of adverse incidents is very much in its infancy with only a limited
number of professionals with the relevant skills to undertake
an effective forensic investigation which is capable of identifying
the often complex chain of events that lead up to an adverse outcome.
3.16 AVMA has for a long time advocated
involving the parents in the investigation of an adverse event.
Parents are often very accurate historians and can provide a
perspective on events which is often not found within the medical
records or from the testimony of staff.
3.17 A small proportion of cases seen by
AVMA involve home deliveries. This does raise some questions as
to the nature of training and supervision required for midwives
to undertake home deliveries as compared to midwives working in
a hospital environment. The level of responsibility and type of
decision making required is quite different in the two settings
and training and accreditation must take this into account.
Protocols
3.18 Clinical protocols and guidelines can
represent a useful tool but if followed blindly can provide a
false sense of security whereby there is a failure to actively
intervene when the protocol is no longer appropriate in light
of changes in either fetal or maternal condition. Such situations
are frequently well-documented in cases seen by AVMA but what
is perhaps obvious by its absence is an intelligent application
of the protocol. It is important that the design of protocols
does not undermine the clinical skills of maternity staff such
that the protocols supersede their own clinical judgement.
4. RESPONDING
TO THE
NEEDS OF
PARENTS FOLLOWING
AN ADVERSE
EVENT
4.1 As little as five years ago, it was
still more often the case that parents faced an uphill struggle
to obtain any form of explanation following a major adverse event
during maternity care. Even after pursuing a lengthy complaint
through the NHS complaints procedure, parents were not guaranteed
to receive a full or accurate explanation.
4.2 There have been some improvements in
terms of providing explanations but this is by no means universal.
Parents are still being given inaccurate or misleading information.
In the aftermath of an adverse outcome occurring during pregnancy
or childbirth, in addition to providing support to help the parents
cope with the trauma, one of the most important issue from the
parents' perspective is information: information about what happened
and why. If the outcome was caused by a failure in the delivery
of care, they need this to be openly investigated and acknowledged.
They also need evidence of the steps that are going to be taken
to prevent a recurrence of the same mistake. This is not just
for the benefit of the individual patient. It is an important
part of clinical risk management generally in that there needs
to be a willingness to openly explore where mistakes have been
made and what action is needed to prevent it happening again.
4.3 AVMA has always advocated a pro-active
approach to responding to adverse events. This means that instead
of waiting to see whether the patient complains, as soon as an
adverse event is identified, an immediate investigation is instituted
which involves the patient and/or relatives.
4.4 Intrapartum stillbirths are a particular
instance where healthcare professionals need to be pro-active
in their approach to responding to the needs of the parents. The
Stillbirth and Neonatal Death Society (SANDS) have produced very
helpful guidelines for health professionals in supporting parents
after a baby has died. However, an essential part of that support
should also include responding to the particular needs of parents
where an adverse event may have played a part in the loss of their
baby. In this situation, a pro-active approach to responding
to the parents concerns is an essential part not only of the support
process, but of patient care.
4.5 AVMA has seen many examples where the
failure to provide an explanation has greatly compounded the parents'
grief, sometimes leading to long-standing psychiatric illness.
In one particular case, a woman had to wait twenty years for an
explanation following an avoidable stillbirth. In the intervening
period she suffered severe depression and was effectively housebound.
It was only following the intervention of a doctor who obtained
her old obstetric records and explained what had happened that
she began the process of recovery. It is not uncommon in the case
of stillbirths to find that mothers will not visit their baby's
grave until their complaint or legal claim is concluded, even
if this is many years after the event.
4.6 If health providers do adopt a pro-active
approach to identifying and investigating adverse events, the
investigation should move away from simply targeting individual
health professionals. Whilst individuals may ultimately be culpable,
there is sufficient data to suggest that attention needs to be
focused on the systems within which those health professionals
work and the sort of failures in those systems which lead to human
error. Such failures may include, for example, systems that allows
people to make decisions beyond their competency or experience,
unsafe staffing levels, poor resourcing resulting in faulty or
substandard equipment, poor communication between health professionals,
inadequate protocols, people working when they are overtired or
stressed etc. An investigation sufficiently rigorous to identify
such failures is not an easy task and requires people trained
to carry out such investigations but is essential if you are going
to address the underlying causes. The present reality is that
the true causes of an adverse event often remain undisclosed.
Individual healthcare professional may well be disciplined but
this will not in itself prevent one of their colleagues making
the same mistake.
5. DISCUSSION
5.1 AVMA acknowledges that improvements
have been made in maternity care but as highlighted in the CESDI
reports and the EuroNatal International Audit, believes there
is no room for complacency, particularly at a time where resources
are being increasingly stretched.
5.2 Giving mothers choice in childbirth
is important but we first need to be able to ensure that as a
minimum, all units are able to provide mothers and babies care
that is safe and that minimises the risks of error and avoidable
adverse outcomes.
5.3 Whilst most of the focus in relation
to obstetric accidents has been on the cost of meeting clinical
negligence claims, this hides the fact that the number of adverse
outcomes, particularly in relation to avoidable stillbirths, is
perhaps no less of a scandal than the tragic events at the Bristol
Royal Infirmary.
5.4 This is a time of considerable change
with respect to the patient safety agenda. Until recently, whilst
the confidential enquiries were able to identify what was going
wrong and why, there were no effective mechanisms for ensuring
that this was translated into the necessary changes in the provision
of maternity services to prevent the same mistakes being repeated.
Following on from the Bristol Royal Infirmary inquiry and the
Chief Medical Officer's report, An Organisation with a Memory
(June 2000), medical accidents or adverse events are now beginning
to be recognised as a key issue in healthcare provision. AVMA
has long argued that patient safety and reducing the frequency
of adverse events should be an underlying principle of all healthcare
policy and provision.
5.5 There have been some significant developments
over the recent past including the introduction of the Commission
for Health Improvement, its role to be reinforced when it becomes
the Commission for Health Audit and Inspection in April 2004;
the establishment of the National Patient Safety Agency to collate
and disseminate data on the frequency and causes of adverse events;
the introduction of clinical governance; and the establishment
of the National Clinical Assessment Authority to address issues
of performance and competency. It is still relatively early days
in terms of assessing whether these developments are sufficiently
robust to prevent another Bristol. There is ongoing concern that
there are still gaps in the regulatory system and that with so
many different bodies dealing with different parts of the regulation
of healthcare, the system is fragmented and there is a real risk
that even cases such as Bristol could still fall between the cracks.
5.6 The first step is to ensure that patient
safety is firmly embedded in the healthcare culture and that medical
accidents are not simply dismissed as "one of those things"
or remain "unexplained".
6. RECOMMENDATIONS
(i) Provide a full 24 hour service with appropriate
consultant and senior midwifery cover.
(ii) Develop more effective systems for identifying
and investigating adverse incidents and for auditing outcomes
so that failures in care can be quickly addressed.
(iii) Set clear targets for reducing the
number of adverse outcomes in maternity care and ensure that the
findings of the CESDI reports and other inquiry systems such as
the NPSA, are translated into practice.
(iv) Incorporate training on adverse incidents
in all clinical training programmes for all members of the team.
(v) Employ a pro-active approach to adverse
outcomes and recognise the needs of parents to have an accurate
and timely explanation. Recognise the contribution that parents
can make to our understanding of the causes of adverse outcomes.
(vi) Recognise the support needs of staff
whilst ensuring poor practice or issues of competency are dealt
with effectively.
(vii) Greater emphasis on communication training,
and in particular, listening skills.
(viii) Further research into the use of oxytocic
drugs in labour and for better training of healthcare professionals
so that they fully understand both the benefits but more importantly,
the risks associated with induction and augmentation of labour.
(ix) Better information for pregnant women
so that they can make an informed choice about interventions.
(x) Minimum enforceable standards for resourcing
of maternity units so that the explanation for an adverse outcome
is not that the unit was "particularly busy" on that
occasion.
(xi) Revise the regulations governing the
private/independent sector to ensure that minimum standards of
clinical care are established.
(xii) Make compliance with CESDI (and other
reporting systems), mandatory for both the NHS and private providers.
February 2003
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