Introduction
The idea that something may go wrong with a birth and/or that a woman may choose to complain or litigate is anathema to those midwives who believe in the process of normal birth and who base their relationships with women on trust. Many midwives are uncomfortable with the concept of risk management, and there is a widespread belief that midwives are being pressured into practising defensively which is at odds with a caring attitude.
The mental distress caused to the injured individual and their family following an adverse event can be immense (Williams & Arulkumaran, 2004). It is easy however to forget the staff involved. A bad outcome can occur however well a midwife has practised. It is even more distressing if someone realises they have made a mistake.
This chapter is, however, intended to both inform and reassure. If midwives practise safely with a good knowledge base, communicate well with colleagues and women and keep good records, they will minimise their chances of an adverse outcome. An understanding of the principles of basic maternity clinical risk management will help all midwives to reflect on their care.
Incidence and facts
- 26% of English NHS litigation cases are maternity issues, but the costs account for 70% of the total NHS litigation sum paid out (Hepworth, 2003).
- A severely brain-damaged child may be awarded over £1 million costs (Williams & Arulkumaran, 2004).
- Despite scare stories there are very few obstetric litigation cases (40–50 between 2002 and 2005) (NHS Litigation Authority (NHSLA), 2007).
- In 2004 there were 2757 maternity complaints in England, Wales and Scotland (Symon, 2006).
- The most common cause of alleged negligence is cardiotocograph (CTG) misinterpretation (Williams & Arulkuraman, 2004).
- Most trusts now have clinical risk management teams to analyse and learn from adverse events.
Clinical risk management: learning from adverse events
Clinical risk management (CRM) is a way of identifying critical incidents and adverse outcomes, to establish if, why and where things went wrong. Root cause analysis can help distinguish individual mistakes by staff from ‘latent failures’ of the organisation. Lessons learned can help reduce the likelihood of recurrence.
Many midwives appear to believe that CRM exists solely to minimise the chances of litigation. While this may be the driver for health service managers to invest money in risk management services (Symon, 2001), it should not make midwives cynical about risk management in principle. Whatever the reason for its evolution, CRM encourages a willingness to learn from our mistakes in a logical and analytical way. This can help midwives to give better care to women, surely something that everyone can relate to.
Unfortunately, CRM in some trusts has been clumsily implemented by weak managers who are quick to leap to simplistic solutions and blame staff. It is vital to implement CRM in a supportive way, involving supervisors of midwives and not to simply make it part of a hierarchical way of controlling midwives. If not, risk management simply becomes another means of enforcing compliance with medicalised policies and protocols and eroding individual clinical judgement. Interpretation of national guidelines, such as those of National Institute for Clinical Excellence (NICE) or Royal College of Obstetricians and Gynaecologists (RCOG) can become very prescriptive, and midwives may feel they have ‘transgressed’ in failing to follow what are, after all, only guidelines, not mandatory practice. Although the midwifery voice is getting louder, the obstetric voice is very much the lead on most national guideline development.
The process of event analysis
Most adverse events occur for not just one but several reasons. The clinician giving the care may be just the last link in the chain of small events, which have led to the incident.
The midwife who links up an intravenous infusion to an epidural catheter may have done so for a complex number of reasons: it is helpful to look at the unit workload, common working practices in that area, training and updating opportunities, as well as the individual’s competence (is this just a one-off aberration for that midwife?) and any obvious ill health issues. It would also be simple to make a practical change that would reduce the chances of a recurrence despite all these factors, e.g. making sure that the epidural tubing is a different colour from the intravenous tubing and labelled with ‘epidural’ stickers. Good incident investigators avoid coming to easy conclusions, but always remain vigilant for simple steps like this to reduce risk.
It is helpful to use a systematic approach to analyse adverse events. The National Patient Safety Agency (NPSA) (www.npsa.nhs.uk) has developed a Root Cause Analysis (RCA) toolkit, which can be supplied free to NHS staff, and a training programme to assist staff in analysis. Ideally all staff involved in an adverse event should meet to review what happened. Often if the case involves many different professionals, this is not practicable unless the outcome was particularly severe, e.g. maternal death.
A well-managed incident review can be a very positive experience. Staff may be able to dispel unfounded guilt, realise what went well or did not, express distress and benefit from the support of colleagues. Real insights into what, if anything, went wrong, and what might be learned to prevent a recurrence or mitigate its effects can improve care in future situations. Conversely, a poorly reviewed case can compound guilt, set staff against each other and fail to prevent a recurrence since nothing has been learned.
All staff can contribute to effective care review in many different ways. It is good to be involved in multidisciplinary case review, but informal methods are often underrated. Anecdotal discussion, including the ubiquitous ‘coffee room chat’, as staff offload their thoughts about recent cases, can be a rich source of insight, support and learning.
Most maternity units also have regular multidisciplinary open meetings to discuss interesting cases/near misses. These tend sometimes to be obstetric led, but midwives increasingly attend and present cases. Such meetings can provide good learning and enhance interprofessional understanding. They are, however, only a broad overview, not a systematic process. The danger is that the most assertive voice may dominate and inaccurate conclusions result. In serious incidents there is no substitute for calm methodical analysis of the notes, statements and verbal accounts.
Litigation
It is unfortunate that much maternity care is based on fear of litigation. Obstetric decision making in particular often tries to contain risk by taking the ‘safest’ line, i.e. intervene early before things go wrong, instead of giving the best care to a woman in labour. Midwives are affected by this fear too, but have overall as a profession somehow managed to resist, to an extent, this overwhelming pressure. This brings them into inevitable conflict with obstetricians at times. This generalisation does not of course take into account that there are many intelligent supportive obstetricians and risk-averse unsupportive midwives.
Women’s rising dissatisfaction with their births (Lane, 2001) may be partly due to rising expectations, but it may also be due to genuine unhappiness at unjustified opposition to their wishes. Whereas some parents may be unhappy with insufficient action, litigation may also, potentially, arise from women denied the normal birth they expected due to unnecessary intervention (Royal College of Midwives (RCM), 2005). If this were to become commonplace, it might refocus the interventionist approach that currently erodes much maternity care.
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