A medical negligence solicitor on the problems of misinterpretation of cardiotocogram traces by maternity staff
Since 1999 I have worked on around 40 to 50 obstetric cases involving cardiotocogram (CTG) errors. I have 18 ongoing obstetric claims, 13 of which have expert evidence identifying misinterpretation of CTG traces as a breach of duty by the hospital staff. I consider that this is a major problem, yet there does not appear to be any sign that lessons are being learnt from the mistakes.
Patient safety must be the priority for the NHS and the focus should be on cutting out avoidable errors. In my experience, the same problems are occurring again and again with catastrophic results.
Families affected by the negligent treatment have to walk away from hospital after giving birth to a child who should have been born perfectly healthy but ended up with severe brain damage. They are often in complete and utter shock; they have to adjust; they have no choice. They put their trust in the hands of the clinicians yet they end up with a life-changing situation. They do not get all the support they need from the state because of lack of resources and often feel that the only thing they can do, to ensure that their child has the care and provisions needed for life, is to sue. I know that we are all only human and mistakes are made but we have to do what we can to try to reduce the number of catastrophic mistakes.
It's time the NHS learnt its lessons, for the sake of all the victims who have been affected and to prevent future victims suffering the same anguish, to ensure it can't happen again and to enable the number of incidents to be reduced. The cost to the families and also to the public because of the payouts is huge.
CTG interpretation is an important part of the labour process. There are certain situations when continuous electronic monitoring is mandatory, yet in some cases midwives or obstetricians do not review the CTG regularly enough and, when they do, fail to consider the clinical picture in context. It is not just looking at a snapshot of foetal wellbeing at the time; it is necessary for the clinician to consider all the factors relevant to that particular labour including the pattern of the CTG over a much longer period, to get a feel for how the baby is coping with the stresses of labour.
CTG is one part of interpreting foetal wellbeing and it is essential to consider the CTG in addition to other known factors in that particular case. A CTG can give an indication that a foetus is in trouble or might soon be. Other tests can then be done to determine whether the baby needs to be delivered immediately. A CTG trace is only as good as the clinician who interprets it.
I can only speak from our experience of cases but the problems include poor training of midwives and/or obstetricians; poor ongoing training to refresh knowledge and keep it up to date; pressures on the labour wards with lack of staff – and NHS cuts may make this worse. It is not just midwives who misinterpret CTG traces; obstetricians do so too. The problems here might be that an obstetrician who dips in and out of the care of a woman in labour, and does not take the time to consider the picture as a whole, might be at risk of just looking at a snapshot of the CTG and thinking that it is normal.
Another problem that we see relates to communication during and over shift changes. Often we see things going wrong after a shift change. It is imperative that there is a good handover so that the midwife or obstetrician coming on duty knows the history of what has been happening in the labour to date and can properly assess the risk and foetal wellbeing. Stresses in labour might deplete a foetus's reserves and ability to cope and if there have been many hours of such stresses but someone coming on duty is not appraised of the issues, they may not be in a position to accurately assess the condition.
Sometimes staff take their eye off the ball because they are so focused on other issues in the labour that even though the CTG monitor is on they fail to look at it, which is unacceptable. In one of my cases, in a high-risk labour with a breech presentation, the midwives came across in the medical records as being so concerned with whether or not informed consent had been obtained by the obstetrician for delivery by caesarean section that they did not seek to ensure that adequate monitoring was in place to check the foetus's condition and when they did eventually start continuous electronic monitoring they failed to recognise that the baby was in distress. The baby in that case was born severely brain-damaged.
The NHS Litigation Authority has all the information from previous cases to ensure the NHS as a whole can learn from its mistakes. It has a duty to improve the way it feeds that information back to labour wards and NHS trusts so that they can identify trends and do something to reduce the number of errors. Upon receiving alerts from the NHSLA about trends in cases, trusts must act to improve patient safety.
Settlements for clients often pay for a lifetime of care – helping them start to put the injuries they have suffered behind them and move on as best they can. But it is not just about the money. For many victims and their families, what they really want is to get an answer as to why this happened, and to ensure it can't happen again to another family.
• Auriana Griffiths is a partner in the clinical negligence department in the London office of Irwin Mitchell solicitors. She specialises in childbirth cases, including those involving misreading of CTG traces.