Clinical Negligence Scheme for Trusts for maternity services (CNST)

https://doi.org/10.1016/S0957-5847(03)00063-5Get rights and content

Abstract

The Clinical Negligence Scheme for Trusts (CNST) has been established since 1994 and is a means by which National Health Service (NHS) Trusts fund the cost of clinical negligence litigation. Maternity services in England account for a significant proportion of the numbers and cost of claims reported to the NHS Litigation Authority (NHSLA). About 60–70% of sums paid out are due to litigation arising from maternity services. This translates to 60–70% of the hospital insurance premium being paid for maternity services. In order to reduce the number of claims against maternity services, the CNST has introduced eight standards for maternity services from April 2003. Discounts to premiums can be obtained according to the compliance met by the individual Trust in accomplishing these standards. Accomplishing these standards is set at three levels. Achieving level 1 standard would bring a 10% rebate, level 2 a 20% rebate and level 3 a 30% rebate. For some trusts, these rebates may amount to half a million pounds. These discounts are valid for the following two financial years. The financial incentive looks attractive but achieving these standards would result in better maternity care and fewer litigations.

Section snippets

Local arrangements and accountability for implementing clinical risk management is clearly defined

There should be a written maternity services risk management strategy that has been approved by the Trust Board. A nominated professional lead has to be charged with responsibility for overseeing clinical risk management throughout the maternity service, ensuring effective and clear lines of communication.

There should be a lead consultant obstetrician and clinical midwife manager for labour ward matters. The maternity services should have a formal group, appropriate to its size, in which

The maternity service pro-actively uses internal and external information to improve clinical care

Achievement of this level involves the demonstration of a robust system of risk management. Systems need to be in place that not only involve the reporting of critical incidences and near misses in all areas of the maternity unit, but also demonstration of analysis of such incidences. The analysis of such incidences and how they may be avoided need to be incorporated in the Trust's system, and policy and guidelines. It is essential that a Trust can demonstrate that this information is

Women are informed by competent professionals of all aspects and options concerning their treatment and care, and there are clearly documented systems for management and communication between professional staff

There needs to be demonstration that communication channels are robust and appropriate to the service and client needs. There is a requirement that a pathway for communication between professionals is incorporated in guidelines, particularly between midwife and consultant. Personal handovers must be undertaken between midwives and medical staff. Locums must receive personal handovers by a senior member of staff.

Women have to be involved in their plans and care. The practitioner explaining a

There are clear procedures for the management of general clinical care

The emphasis for this section relates to the availability of evidence-based guidelines. These need to be easily identifiable and available in all departments including Accident & Emergency. They must include clear information regarding the criteria of transferring a woman to high-dependency care and the effective transference of information. Resource information must be available for the professionals to access when caring for women who have had a stillbirth or late miscarriage. Guidance must

There are managed systems in place to ensure the competence and appropriate training of all professional staff

An induction system needs to be in place for all staff including agency, bank and locum staff. The package in place must endeavour to ensure that the staff employed are capable of undertaking the role to which they are employed. Verification of appropriate registration must occur. All new starters must attend mandatory induction days.

All appropriate professionals must be able to undertake maternal and/or neonatal resuscitation as required. Records must be maintained. All maternity and obstetric

A comprehensive system for the completion, use, storage and retrieval of health records is in place. Record-keeping standards are monitored through clinical audit process

The Trust needs to ensure that there are medical records that all specialities can use. These notes need to be accessible 24 h/day, 7 days/week. Their design should enable one to obtain pertinent information, and should be structured in such a way as to reduce the risk of lost documents.

There is a requirement that regular audit of the maternity notes take place in a multi-disciplinary fashion in order to assess the quality of record keeping. The essential standards are that the notes are written

A clinical risk management system is in place

All clinical risk management standards and processes should be in place and operational. Risk management policy should be implemented through the general management arrangements of the maternity service. A clinical risk assessment should have been conducted throughout the maternity service. There should be evidence of progression and achievement of action points based on the recommendations.

Maternity services must provide safe care for mothers at all times

Clear arrangements need to be in place for statutory supervision of midwives. It must be demonstrated that there are dedicated obstetric anaesthetic services available in all consultant units. The labour ward must have sufficient medical leadership and midwives available to provide a reasonable standard of care at all times.

Conclusion

The standards for CNST are the concern for all staff working within a Trust. Achieving the standards for maternity services to the highest level will improve the service experienced by women and their families, as well as reducing litigation costs and risk incidents. For such standards to be met, it is imperative that all levels of staff and disciplines are involved, and work together in a seamless manner.

Practice points

  • Protocols and guidelines need to be regularly updated, referenced and made available to

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