In the UK each year there are over 1,000 avoidable baby deaths or babies born with severe brain injury. This prompted the Each Baby Counts project which aimed to reduce unnecessary suffering and loss of life by 50% by 2020.
In April 2017, the Healthcare and Safety Investigation Branch (HSIB) was set up as an independent branch of NHS Improvement to investigate serious incidents in the NHS.
In November 2017, the then secretary of state for health, Jeremy Hunt announced a new maternity safety strategy and HSIB was asked to undertake around 1000 independent safety investigations relating to maternity care, the purpose of which was to identify themes and draw out wider learning.
A maternity implementation team was set up and the programme started in April 2018 in the South East region, with full coverage across the South of England from 1 July 2018.
HSIB aims for full national coverage by April 2019.
What is the criteria?
HSIB will investigate maternity cases involving a term baby (37+ weeks) where the following occurred:
- Intrapartum stillbirth
- Early neonatal death
- Severe brain injury
It will also investigate where there has been a maternal death occurring during pregnancy or up to 42 days after pregnancy.
What has been happening since April 2018?
On 30 November 2018, I was pleased to be able to attend the AvMA Specialist Clinical Negligence Panel meeting where Louise Page, Clinical Advisor at HSIB provided an update.
HSIB is an independent body and aims to involve the family throughout the process. It is clear that the investigation is about learning and not about blame. The aim is to improve quality of care and reduce avoidable deaths and injury alongside the Each Baby Counts project.
Each investigation has involvement of an independent team consisting of an obstetrician, midwife and neonatologist depending on the individual circumstances. The report will then be shared with the trust and the family.
However, no official data is yet available and an annual review will be published on the HSIB website in due course with recommendations for improvements at a national level.
Are hospitals undertaking their own investigations?
The HSIB investigations replace trusts’ own internal Serious Incident reporting. Where a serious incident has occurred such as a neonatal death, hospital trusts should carry out their own investigations by way of Serious Incident Investigation report.
However, the Each Baby Counts 2018 progress report (Seen at the end of the article) found a number of worrying findings including:
- Only 41% of parents were invited to take part in reviews
- In 22% of reviews parents were not made aware of reviews taking place
- Only 48% of local reviews involved serious management
- Only 10% of local reviews included an external reviewer
The HSIB report will be shared with the trust with the aim of sharing recommendations and learning to improve quality of care.
What is the role of the coroner?
Where a death is unexplained or unnatural, it is mandatory for a coroner’s investigation to take place and there is often an Inquest.
However, the coroner cannot currently investigate stillbirths or deaths before 24 weeks gestation. This is set to change, with the government recognising that stillbirths need to be reported and investigated by the coroner as much as a neonatal death. However, The Civil Partnerships, Marriages and Deaths (Registration Etc.) Bill is still at reporting stage and it is not known when the bill will come into effect. This makes the HSIB involvement even more important.
Early Notification Scheme
HSIB will notify NHS Resolution (an NHS body which works to compensate for negligent care and resolve concerns and disputes) leading to opportunities for early settlement of cases. The potential implications for early settlement are explored in a related article: Should I settle my medical negligence compensation claim directly with NHS resolution?
It is very important that specialist advice is received before agreeing any settlement. Once a settlement is agreed, compensation is provided on a full and final basis and therefore if it is later discovered that there has been an under settlement or a claimant’s condition worsens, no further claim for compensation can be made. Any settlement made on behalf of a child or someone who lacks capacity should be approved by the court.
HSIB reports and claims for compensation
It is hoped that HSIB investigations will give families answers and reassurance that lessons have been learnt and actions changed as a result of their particular case.
However, often compensation is also needed to pay for care and treatment for the injured party and legal advice should be sought from a specialist. If you have any queries about this article or have suffered injury as a result of medical negligence, please contact Jennifer Waight on 01892 701374 in confidence.