Analysis of Cerebral Palsy Claims managedby Minter Ellison Lawyers Brisbane over thelast 20 years.Presented by Stephanie J...
OverviewGeneralStatisticsBreach ofDutyCausationInvest-igationQuantumRiskManagementStrategies
GeneralStatistics• Increase in instructions toinvestigate potential CP claimsfor babies born in 2004 andremained high sinc...
General Statistics• Significant CP matters takeon average 4.5 years frominstruction to resolution or8.5 years from birth t...
Breach of DutyDelay in performing caesarean section26.35% of issues investigatedInadequatemonitoring ofthe fetal heartrate...
Breach of Duty• Further allegations related to:• Antenatal care• Management of infection in pretermpremmie or prolonged ru...
Breach of Duty• Failure to appreciate hyperstimulation/ riskof uterine rupture• Failure to recognise/manage dystocia• Fail...
Breach of Duty• Failure to act on abnormal scalp lactatelevels• Delay in obstetrician attending• Inadequate antibiotic cov...
Breach of Duty
Case Example 1• Delay in decision to notify GP obstetricianfollowing decelerations on CTG• Attempts to contact on call GP ...
Breach of Duty• Little shift with the main exposureareas• Ongoing issues - induction &vacuum extraction• Recent issues:• a...
Breach of Duty• Expect neonatal care claims toincrease as studies continue toshow a potentially significantimprovement in ...
Case example 2• Non-insulin dependent gestational diabetes• Apgars 9 at 1 and 5.• Disinterest in feeding, Jitteriness,Slee...
Acute/peripartumChronicwith orwithoutsecondaryhypoxiaCausation• Terms such asbirth asphyxiaand intrapartumasphyxia nowoutd...
Causation • CP rates same for 40 years despite6-fold increase in C-section rates &liberal induction policies to reducepost...
Causation• There will always be an expert willing to saythat if the baby had been born 10 minutesearlier he or she would h...
Causation factors• Maternal BMI?• Genetic anomaly• Infection• Prematurity• Cytokine storm• Raised neonatal red blood cell ...
Case Example 3• Possible 20 minute delay in notifyingobstetrician and 10 minute delay after type1 decelerations• Obstetric...
Investigations• Undertake the followinginvestigations where a baby isborn compromised or deterioratesneonatally, where pos...
Investigations• Record Apgar scores• Measure baby’s lactate levels• Take MRI at day 2 to 4 and day 10• Consider DNA invest...
Investigations• Maternal and neonatal serology(TORCH infections)• Lochia culture• Blood mycoplasma serology• Kleihauer-Bet...
Investigations• Urine culture• Tests to investigate maternal or neonatal:• hypothyroidism,• maternal thrombophilia,• mater...
Further Medical Examinations• In consultation with causationexperts consider:• Chromosomal map• Genetic evaluation• Matern...
Mother’s Medical Records• Ensure it is complete including:• Mother’s medical history• Mother’s antenatal history• Maternal...
Baby’s Medical Records• Results from all tests undertaken• All pathology results, particularly cord blood• All radiology r...
Case example 4• Obstetrician kept notified of slow progress,small amount of meconium, anddecelerations• Clear documentatio...
Quantum• Estimate for CP matters in Qld is now in therange $6M to $8M plus administration fees(these can be in the vicinit...
Quantum - Care• Certainly a shift upwards in care awards• About $4M for care of significantlydisabled claimant, somewhere ...
Queensland
NSW
Other states
International Comparison• VanSlembrouck v William Beaumont Hospital– Michigan US 2011 - $144m reduced to$40m due to legisl...
Risk Management Strategies• Management of expectations antenatally• Notify and document• Monitoring of fetal wellbeing and...
Analysis of Cerebral Palsy Claims managedby Minter Ellison Lawyers Brisbane over thelast 20 yearsPresented by Stephanie Jo...
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Evaluating Cerebral Palsy Claims

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Stephanie Jones, Senior Associate, from Minter Ellison Lawyers has presented at the Obstetric Malpractice Conference. If you would like more information about the conference, please visit the website: http://bit.ly/10xh1iO

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Evaluating Cerebral Palsy Claims

  1. 1. Analysis of Cerebral Palsy Claims managedby Minter Ellison Lawyers Brisbane over thelast 20 years.Presented by Stephanie Jones, SeniorAssociateJune 2012
  2. 2. OverviewGeneralStatisticsBreach ofDutyCausationInvest-igationQuantumRiskManagementStrategies
  3. 3. GeneralStatistics• Increase in instructions toinvestigate potential CP claimsfor babies born in 2004 andremained high since.• 66% of instructions received donot proceed,– most because they do notcommence,– a large number arediscontinued or do notprogress further,– the claimant dies or the matteris dismissed in the minority.• Public / private splitfor investigations/claims is44.9%/55.1%
  4. 4. General Statistics• Significant CP matters takeon average 4.5 years frominstruction to resolution or8.5 years from birth toresolution.• Those that did not progresstook an average of 2.77years from instruction toresolution or 6.8 years frombirth to resolution.• It takes claimants onaverage 4 years toinstruct lawyers.
  5. 5. Breach of DutyDelay in performing caesarean section26.35% of issues investigatedInadequatemonitoring ofthe fetal heartrate & failure torecognise fetaldistressDelay innotifying, orfailure to notify,the obstetricianNeonatal care
  6. 6. Breach of Duty• Further allegations related to:• Antenatal care• Management of infection in pretermpremmie or prolonged rupture ofmembranes• Management of cord prolapse• Use of syntocinon wherecontraindicated or dosage issue• Mismanagement of premature labour
  7. 7. Breach of Duty• Failure to appreciate hyperstimulation/ riskof uterine rupture• Failure to recognise/manage dystocia• Failure to offer, or delayed, instrumentaldelivery• Mismanaged or delayed diagnosis ofhypoglycaemia• Ventouse delivery
  8. 8. Breach of Duty• Failure to act on abnormal scalp lactatelevels• Delay in obstetrician attending• Inadequate antibiotic cover• Failure to adequately impress upon theparents the need for intervention
  9. 9. Breach of Duty
  10. 10. Case Example 1• Delay in decision to notify GP obstetricianfollowing decelerations on CTG• Attempts to contact on call GP obstetricianunsuccessful causing further delay• 1.5 hr decision to delivery interval• CP
  11. 11. Breach of Duty• Little shift with the main exposureareas• Ongoing issues - induction &vacuum extraction• Recent issues:• antenatal care allegations, such asfailure to diagnose or appropriatelymanage vasa praevia, and• neonatal care, particularlyhypoglycaemia, failure to call apaediatrician and the resuscitationprocess
  12. 12. Breach of Duty• Expect neonatal care claims toincrease as studies continue toshow a potentially significantimprovement in prognosis whenneonatal care meets theconstantly shifting, and research-driven, standards.
  13. 13. Case example 2• Non-insulin dependent gestational diabetes• Apgars 9 at 1 and 5.• Disinterest in feeding, Jitteriness,Sleepy/floppy• Paed says monitor• 36 hours post birth BSL 0.8mmol• CP
  14. 14. Acute/peripartumChronicwith orwithoutsecondaryhypoxiaCausation• Terms such asbirth asphyxiaand intrapartumasphyxia nowoutdated.• ‘Hypoxicischaemicencephalopathy’replaced with‘neonatalencephalopathy’
  15. 15. Causation • CP rates same for 40 years despite6-fold increase in C-section rates &liberal induction policies to reducepostmaturity• Not been shown that earlier rapiddelivery of fetus by c-section, due tonon-reassuring CTG patterns,changes the risk of CP outcome• Neuropathology of CP is oftenestablished silently during pregnancy& neurological compromise oftendoes not appear until stresses oflabour, detected with increasedmonitoring during labour or afterdelivery
  16. 16. Causation• There will always be an expert willing to saythat if the baby had been born 10 minutesearlier he or she would have been born inperfect condition• It will always be a risk to defend a CP claimoutright if there is the possibility of a findingof breach of duty, even with the bestcausation evidence available
  17. 17. Causation factors• Maternal BMI?• Genetic anomaly• Infection• Prematurity• Cytokine storm• Raised neonatal red blood cell count
  18. 18. Case Example 3• Possible 20 minute delay in notifyingobstetrician and 10 minute delay after type1 decelerations• Obstetrician attended quickly then allowedmum to push before proceeding to forcepsdelivery about 1 hour after abnormal CTG• CP• Causation complicated by likely contributionof neonatal sepsis
  19. 19. Investigations• Undertake the followinginvestigations where a baby isborn compromised or deterioratesneonatally, where possible, withincost constraints and with consentwhere required:• Send placenta to pathology forculture and ensure it is retained• Note and record appearance ofumbilical cord• Collect cord blood and send topathology, ensuring it is retained
  20. 20. Investigations• Record Apgar scores• Measure baby’s lactate levels• Take MRI at day 2 to 4 and day 10• Consider DNA investigation• Undertake multiorgan function tests• Consider a lumbar puncture and store someCSF for metabolic studies
  21. 21. Investigations• Maternal and neonatal serology(TORCH infections)• Lochia culture• Blood mycoplasma serology• Kleihauer-Betke test• Test nucleated red blood cells• C-reactive protein (maternal)• White blood cells (mum and bub)
  22. 22. Investigations• Urine culture• Tests to investigate maternal or neonatal:• hypothyroidism,• maternal thrombophilia,• maternal and/or neonatal anaemia,• thrombocytopaenia• Search for microorganism in liquor, blood, earand indirect signs of neonatal infection
  23. 23. Further Medical Examinations• In consultation with causationexperts consider:• Chromosomal map• Genetic evaluation• Maternal neuroimages• Vaginal culture duringpregnancy
  24. 24. Mother’s Medical Records• Ensure it is complete including:• Mother’s medical history• Mother’s antenatal history• Maternal BMI• Fetal movements during pregnancy• Any maternal fever during labouror history of UTI• CTG – crucial where it exists• Partogram• Database records such apathology, radiology, etc
  25. 25. Baby’s Medical Records• Results from all tests undertaken• All pathology results, particularly cord blood• All radiology records and images• Any relevant photographs• Seizure activity history• Resuscitation record
  26. 26. Case example 4• Obstetrician kept notified of slow progress,small amount of meconium, anddecelerations• Clear documentation to support• Decision to delivery interval 13 minutes• Apgars 8 at 1 and 10 at 5• Brain injury
  27. 27. Quantum• Estimate for CP matters in Qld is now in therange $6M to $8M plus administration fees(these can be in the vicinity of $1M) pluscosts ($200,000 for the claimants costs and$80,000 for defence costs).• Many factors in overall settlement amountincluding life expectancy and causationarguments• Major recent changes have been increase incost of care and significant increase inadministration fees
  28. 28. Quantum - Care• Certainly a shift upwards in care awards• About $4M for care of significantlydisabled claimant, somewhere between$55,000 and $65,000 per year of life• Key factor in determining likely careaward is market cost• Market costs likely to increasesignificantly following Fair WorkAustralia Equal Remuneration Case[2012] FWAFB 1000, which includedincrease in carer’s wages from 19% to41% to be implemented over 8 yearperiod
  29. 29. Queensland
  30. 30. NSW
  31. 31. Other states
  32. 32. International Comparison• VanSlembrouck v William Beaumont Hospital– Michigan US 2011 - $144m reduced to$40m due to legislative caps and presentvalue costing.• Largest single personal injury verdict in UShistory.• Hospital appealing.
  33. 33. Risk Management Strategies• Management of expectations antenatally• Notify and document• Monitoring of fetal wellbeing andinterpretation of results• Policy review and compliance (egsyntocinon, hypoglycaemia, prematurelabour, prophylactic antibiotics)• Early investigation and policy re parameters• Communication
  34. 34. Analysis of Cerebral Palsy Claims managedby Minter Ellison Lawyers Brisbane over thelast 20 yearsPresented by Stephanie Jones,Senior AssociateJune 2012

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