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NHS Resolution report identifies issues with fetal monitoring as being major contributing factor in newborn brain injuries

NHS Resolution report identifies issues with fetal monitoring as being major contributing factor in newborn brain injuries

A new report [1] has been published by NHS Resolution today providing an analysis of maternity cases processed through the organisation’s new Early Notification scheme, during its first year of operation (2017/18). This initiative aims to support both staff and families through a requirement for early reporting (within 30 days) to NHS Resolution of all term babies diagnosed with a potentially severe brain injury in their first week of life.
Early involvement of the clinical negligence expertise of NHS Resolution is aimed at accelerating the identification of cases of clinical negligence, and thereby accelerating admission of liability; provision of necessary support and candour to families; and time-limiting the stress of investigations for the professionals involved. The scheme is also designed to reduce rising litigation costs to the NHS by reducing the need for formal court proceedings and increasing the potential to learn from harm and drive improvement.

Quicker Learning & Benefits to Families

The report states that admissions of liability were provided for 24 families, all within 18 months of the birth compared to the long waits in the past – which could have been for several years. Families were provided with a detailed explanation, an apology, independent representation, and financial support for prompt clinical and respite care, as well as psychological support where required.

Key Learning Points

An analysis of a sample of 96 of the total 197 cases where NHS Resolution panel solicitors were instructed to investigate liability, identified the following issues:

  • Investigations included limited support to staff, insufficient family involvement, and confusion over duty of candour.
  • Issues with fetal monitoring were a leading contributory factor in 70% of cases. In 63%, at least two or more factors were identified; a delay in acting on a pathological CTG was the most common factor.
  • Impacted fetal head and/or difficult delivery of the head at caesarean section was a contributory factor in 9% of cases in this cohort. This is a high incidence for a problem that has not previously been highlighted by NHS Resolution.
  • Concurrent maternal medical emergencies in labour occurred in 6% of these cases. Significant maternal hyponatraemia was highlighted as an emerging contributor to neonatal seizures and encephalopathy.
  • Immediate neonatal care and resuscitation remains an important but under-recognised factor affecting 32% of the cohort.

A Spotlight on Fetal Monitoring

The report found that the most common contributory factor in cases where babies were born with brain damage was staff failing to act on abnormal cardiotocographs (CTGs) during labour, with it being involved in 70% of cases. This supports and repeats findings from other reports dating back to the CESDI reports in 1996 [2-6]. Fetal monitoring, including CTG, is a tool to assess the baby’s well-being during labour.

NHS England has recommended effective fetal monitoring, including cardiotocograph (CTG) interpretation, in labour as one of the key elements of care designed to tackle adverse perinatal outcomes, such as stillbirth. Saving Babies’ Lives Version Two [7] – a care bundle for reducing stillbirths and neonatal deaths – stated that “trusts must be able to demonstrate that all qualified staff who care for women in labour are competent to interpret cardiotocographs (CTGs)”. Fetal Monitoring Leads have also been recommended in every trust, who will have the responsibility of improving the standard of fetal monitoring. Interventions in improving this include multi-professional annual training for relevant staff.

With recommendations being published regularly on the subject, and training being made widely mandatory in most NHS trusts, why does there seem to be an ongoing challenge with getting this right?

Part of the Picture: Lack of Standardisation

  • Interpretation: An incorrect classification was found in almost half (43%) of cases reported to NHS Resolution. There are a multitude of different guidelines and language used to assess, escalate, and manage fetal monitoring output – there needs to be an agreed language and method based on robust evidence and including the wider clinical picture involving mum and baby.
  • Culture: A delay in acting on a pathological trace or abnormal fetal heart was found in over half of cases (52%), and a delay in escalation was found in almost half (45%). Communication and decision-making need to be improved, and work investigating cultural themes should be carried out to better understand the barriers. Shared language and knowledge should be encouraged nationally to encourage effective and timely communication.
  • Training: Baby Lifeline’s report, Mind the Gap 2018 [8], showed that 99% of trusts provided training in electronic fetal monitoring/CTG, and considered it mandatory for at least one staff group; however, there is still variability nationally in the content of training in fetal monitoring as well as the administration, attendance, and assessment.  For example, almost a quarter of trusts mandated training every 6 months (21%), around 3 out of 4 trusts mandated attendance annually (72%), and some trusts varied from more than once every 3 months to every 2 years. In addition, a third of trusts did not assess training on the topic.

What is Baby Lifeline doing to help?

Baby Lifeline works collaboratively with leading experts and organisations to develop evidenced-based training to help front line maternity professionals to deliver safe maternity care and reduce avoidable harm. Baby Lifeline’s research programmes are aimed at evaluating the impact of high-quality CPD training for frontline maternity professionals, and our Mind the Gap series aims to provide an ongoing national picture of the provision of training to maternity professionals in the UK.

Relevant to today’s report, our new 2-day training course, Learning from Adverse Events in Maternity Services provides delegates with training and guidance in areas including family engagement, duty of candour and supporting staff following adverse events.

Our CTG Masterclass and Advanced CTG Masterclass courses provide expert-led an evidenced-based training in cardiotocograph (CTG) interpretation, based on an understanding of fetal physiology and appreciation of the wider clinical picture, and aimed at providing delegates with the confidence to provide individualised care to women in labour.


Baby Lifeline welcomes today’s report, especially the recommendations for urgent further research into effective improvement strategies for fetal monitoring. Baby Lifeline’s Mind the Gap 2018 report [8] supports findings by NHS Resolution that there is a lack of standardisation nationally in the training provided to maternity professionals in this area. NHS professionals must be fully supported to implement best practice guidance to reduce avoidable harm in maternity care.


  1. NHS Resolution. (2019) The Early Notification scheme progress report: collaboration and improved experience for families. Retrieved 25th September 2019 from:
  2. Health, T. D. (1996). Confidential Enquiry into Stillbirths and Deaths in Infancy. 3rd Annual Report, 1 January–31 December 1994. The Department of Health.
  3. NHS Litigation Authority (October 2012). 10 Years of Maternity Claims. London: NHS Litigation Authority.
  4. Gynaecologists, T. R. (2015). Each Baby Counts. London: The Royal College of Obstetricians and Gynaecologists.
  5. Magro, M. (2017). Five Years of Cerebral Palsy Claims. NHS Resolution.
  6. Draper ES, K. J.-U. (2017). MBRRACE-UK 2017 Perinatal Confidential Enquiry: Term, singleton, intrapartum stillbirth and intrapartum related neonatal death. The Infant Mortality and Morbidity Studies. Leicester: Department of Health Sciences, University of Leicester.
  7. NHS England. (2019). Saving Babies’ Lives Version Two: A Care Bundle for Reducing Perinatal Mortality. Retrieved 25th September 2019 from
  8. Ledger, S., Hindle, G. and Smith, T. (2018). Mind the Gap, An Investigation into Maternity Training for Frontline Professionals Across the UK (2017/18). Retrieved 14th March 2019, from


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