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Learning from tragedy: hospitals' response to the severe brain damage of 15 babies

By Sarah Loxley

Published In: Clinical Negligence

In the realm of healthcare, the safety and well-being of patients, especially the most vulnerable, are paramount. However, recent events involving 15 babies who were left with severe brain damage following “likely” or “possible” “substandard” care in Derby and Burton have cast a dark shadow over this fundamental principle.

Image of Maternity ward sign

These incidents at the University Hospitals of Derby and Burton NHS Foundation Trust, which runs the Royal Derby Hospital and Queen’s Hospital Burton, have sparked outrage and prompted deep reflection within the healthcare community.

Recently, the inquest into the death of Ethan Blackwell at Royal Derby Hospital revealed a series of missed opportunities and failures in care that ultimately led to his death. Testimony from Senior Clinicians emphasised that Ethan's birth should have occurred much earlier and different actions could have saved his life. Key focus was on the crucial two-hour period between significant drops in heart rate, where intervention could have led to a timely section. Concerns were raised about false assurances regarding Ethan's health, inaccuracies in monitoring equipment, and inadequate communication with his parents.

A review was carried out by NHS Resolution throughout November 2022 into 28 cases referred to it by the trust between April 2017 and November 2022. These cases involved incidents where the babies suffered “a potentially severe brain injury” within the first seven days of their life. It found that six of the cases referred by the trust involved “likely substandard care” and a further nine cases involved “possible substandard care”.

The review of the Trust identified several key failures contributing to delays and adverse outcomes in childbirth cases:

1.     Poor CTG interpretation : One of the most common themes was the misinterpretation of CTG (cardiotocography) readings, which monitor the baby's heart rate. Delays in recognising concerning features and escalating care accordingly were noted.

2.     Delays in birth process : Issues such as delays in escalating for further support or sections, as well as delays in delivering equipment, were identified. In critical situations, junior staff members often took the lead instead of senior staff, leading to potential delays in decision-making and intervention.

3.     Assisted birth delays : Decision-making regarding assisted births, including transfers, considerations, and technical issues, was often delayed. There were instances of too many attempts at assisted birth before resorting to sections, and junior clinicians were sometimes tasked with procedures despite abnormal CTG readings.

4.     Inadequate handover and information sharing : Several cases highlighted significant issues with handovers or lack of information transfer between healthcare providers, which could have impacted patient outcomes.

5.     Neonatal team absence : In multiple cases, the team was not present at the birth, potentially delaying critical interventions and care for newborns.

6.     Infrastructure and resource challenges : Challenges such as delays in transferring patients to theatre due to limited availability, as well as insufficient equipment, contributed to delays in care delivery.

7.     Improvement recommendations : The review recommended improvements such as ensuring emergency cases involve the team, categorising sections by priority, and enhancing awareness of and patient deterioration throughout the pregnancy journey.

Despite these failures, the review also noted instances of good practice, particularly in supporting women with complex medical or needs and those with pregnancies involving fetal/genetic complications. However, addressing the identified shortcomings is crucial for enhancing patient safety and outcomes in childbirth.

Following the sorrow and scrutiny, it appears that the hospital trust is beginning to take proactive steps to learn from these tragic mistakes and prevent similar incidents in the future. They assert they have already made changes to how they monitor the heartrate of babies during labour, invested in new equipment and training and introduced twice-daily handover meetings between senior obstetric, anaesthetic and midwifery colleagues. They have also recruited additional doctors and sonographers, along with 46 new midwives since August, which now gives them one of the best-staffed units in the region and allows their teams to better provide the compassionate and safe care they strive for. The trust says there have been no safety investigation referrals involving monitoring concerns since October 2023.

Whilst the trust’s own interim executive medical director agrees they still “have much further to go”, there is a concern amongst clinical negligence lawyers of a culture of "failing to learn from mistakes" within the trust, citing numerous instances of adverse outcomes and missed opportunities for improvement.

Over the past couple of months, first with the Shrewsbruy and Telford Hospital NHS Trust review and then Nottingham University Hospital NHS Trust’s review which found a number of failings with over 300 cases contributing to still births, deaths and brain injured babies and now the failings by Derby and Burton, more and more families are being left to care for children with catastrophic injuries or are tragically losing their babies.

In the aftermath of these tragedies, families affected by the severe brain injuries and losses are seeking answers and accountability. Legal scrutiny and grave concerns about the circumstances surrounding these incidents have been raised. Families rightfully demand transparency and accountability from healthcare providers, as they grapple with the profound and enduring consequences of these preventable errors.

Contact our specialist medical negligence team

At Switalskis, we consistently find ourselves assisting numerous families who are left to navigate the aftermath of inadequacies in maternity care. They are finding themselves with inadequate support and in a social care system which is also stretched to its limits. There is therefore an urgent need for tangible changes to prevent further harm to mothers and babies.

If you think you have received inadequate or delayed treatment during labour or you have affected by any of the above, you may have a medical negligence claim. If you feel that this applied to you or anyone you know, please reach out and make contact with us so that we can begin to support you. Call 0800 138 0458 or email .  

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Sarah is a trainee solicitor in our medical negligence team focusing on complex, high value claims.

Trainee Solicitor

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