Early Notification – Rapid Resolution and Redress
27th March, 2017
The NHSLA is introducing an 'Early Notification' process for high value maternity incidents.
From 1st April 2017 the NHSLA will require members to notify them of all maternity incidents which have resulted in severe brain injury.
What are the criteria for early notification?
The criteria have been taken from the ‘Each Baby Counts Programme’ of the Royal College of Obstetricians and Gynaecologists (RCOG) and are:
Babies born at term (≥37 completed weeks of gestation), following labour, with a severe brain injury diagnosed in the first seven days of life, namely babies that had one or more of the following:
- Diagnosed with grade III hypoxic ischaemic encephalopathy (HIE);
- Actively therapeutically cooled;
- Had all three of the following signs: decreased central tone; comatose; seizures of any kind.
The above criteria have been identified by the RCOG as being potential markers for severe brain injury at birth and for potentially avoidable harm.
It will be mandatory for Trusts to report any incidents which fall into the above criteria and they must do so within 30 days of the incident occurring.
What information should be provided?
The NHSLA does not wish to increase the administrative burden of clinicians and so the details to be provided will be brief. The information is likely to be similar to the report form for Each Baby Counts.
Once the incident has been reported, the NHSLA wishes to work with Trusts in tandem with their statutory duty of candour investigations, with an aim to providing support to the maternity and legal teams, and to share learning across members. The service envisaged would offer the following:
- Building a national network to provide Peer support for affected healthcare staff;
- Advice and practical help on delivering candour in practice;
- Point of incident mediation where the relationship between the organisation and the family is at risk of breaking down; and
- Preservation of records and other evidence, and where indicated, a preliminary investigation of legal liability.
Investigations will start at an early stage into those cases where there is a risk of liability.
Where the early investigation does not identify negligence, the NHSLA will assist members with internal investigations and in responding to families in accordance with the duty of candour.
In some cases the risk of liability will be low and may not warrant investigations into liability.
How long should records be kept for?
Regardless of the assessment of the risk of liability, in all cases reported the NHSLA will require records to be retained for a period of 75 years. Further information will be provided as to how this retention of records will be achieved.
The NHSLA are to create an internal team to administer the scheme, which will include legal and clinical experts.
In the meantime they have asked if we have any nominations for the ‘Peer Support’ programme.
They are looking for any clinicians or midwives who have been involved in a previous cerebral palsy case, and who would be willing to provide support to a colleague in a similar position.
If there is anyone that you consider would be interested in this position then please let us know and we will provide further details.
For further information in relation to the above please get in touch.
Please note that this briefing is designed to be informative, not advisory and represents our understanding of English law and practice as at the date indicated. We would always recommend that you should seek specific guidance on any particular legal issue.
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