One example from our strategy of this change in focus and complementing the work of others in the system is our Early Notification scheme. We have identified some early indicators to incentivise improvements in maternity safety which are aligned with elements of the Royal College of Obstetricians and Gynaecologists’ (RCOG) Each Baby Counts national quality improvement programme. It is now a requirement for trusts to report all maternity incidents occurring on after 1 April 2017 which are likely to result in severe brain injury.

Please refer all babies born at term (≥37 completed weeks of gestation), following labour, that had a potentially severe brain injury diagnosed in the first seven days of life, the criteria are:

  • 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.

We will then be able to increase the level of support we provide to teams when these rare incidents occur.

Some of the information requested by NHS Resolution is already being submitted to Each Baby Counts, and NHS Resolution and the RCOG are working together to develop an approach towards collection of this data to ensure trusts do not need to submit the same data twice.

The following process is:

  • Data is submitted to the RCOG Each Baby Counts programme as usual.
  • The trust legal services department is informed within 14 days of the incident that a notifiable severe brain injury incident under the Early Notification Scheme has occurred using the Early Notification report form
  • The trust legal services department should then report the incident to NHS Resolution within 30 days of the incident.

The support services we will be able to provide will include 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; aiding the preservation of records and other evidence; and where indicated, a preliminary investigation of legal liability.