This report provides an in-depth examination of the causes of these rare but tragic incidents and the investigations that follow them. For the purposes of this study we focused on 50 cases of cerebral palsy where the incidents occurred between 2012 and 2016 and a legal liability has been established.
Working in partnership with other organisations, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, NHS England and NHS Improvement, we have highlighted areas for improvement and made clear recommendations to help trusts prevent further incidents.
The study draws upon the unique data set we hold to address two key areas for improvement; training to prevent future incidents and the quality of serious incident investigations.
We’ve also created a summary of the report which you can access below.