What impact will the Maternal Care Bundle have on future claims?

In response to a sharp increase in maternal deaths, NHS England has published the Maternal Care Bundle (MCB). The MCB identifies 5 areas of maternal care where the risk of maternal mortality is increased – what impact will it have in assessing future clinical negligence claims?

The MCB aims to reduce maternal mortality. It responds to MBRRACE UK data which shows a 21% rise in maternal deaths since 2009–11, and that 45% of maternal deaths had potentially preventable elements

The MCB sets national minimum standards across five high risk clinical areas of maternal health: - venous thromboembolism (VTE), pre hospital and acute care, epilepsy in pregnancy, maternal mental health, and obstetric haemorrhage. The minimum standards must be implemented by NHS Trusts and ICBs by March 2027

1. VTE

• Early pregnancy VTE risk assessment will be offered at the first NHS contact, not at booking.
• Rapid access to LMWH within 72 hours is to be provided for high risk women.
• Standardised dosing of LMWH will be introduced.

2. Pre-hospital and acute care

• There will be a mandatory implementation of MEWS across all settings for women who are, or have been, pregnant in the past 4-weeks.
• Standardised pre alert systems between the ambulance and labour ward will be introduced, alongside clear labour ward signage.
• Clear referral pathways for acutely unwell women from local services to maternal medicine centres will be implemented.

3. Epilepsy in pregnancy

• There will be guaranteed access to a local epilepsy in pregnancy team (consisting of an obstetrician, obstetric physician and epilepsy nurse specialist or neurologist), who will lead care plans.
• Women requiring more complex care must be referred to a maternal medicine network MDT to oversee the provision of care.

4. Maternal mental health

• There will be routine wellbeing screening throughout pregnancy and women should be invited to self-administer the Whooley questions.
• Where there are concerns, the patient will be invited to complete the EPDS.
• Where women score 13 or above in total, or 2 or above on self-harm, there will be a conversation to discuss care options, agree next steps and arrange referrals. 

5. Obstetric Haemorrhage

• There will be mandatory cumulative measured blood loss for all births
• Standardised escalation steps at 500 mL, 1,000 mL, and 1,500 mL are to be introduced, with consultant involvement for ongoing bleeding.
• MDT case review will be required for all women who suffer >2 L blood loss or use fibrinogen/cryoprecipitate within a month.

The MCB establishes baseline standards in maternal care, albeit only in the above areas of concern. 

In respect of future claims, we can expect that the MCB will be used by solicitors to evidence breach of duty. Because the standards are specific, time-limited and standardised, they are likely to be treated by the courts as evidence of what the standard of reasonable care is in the above scenarios. Any deviation from the MCB standards will likely constitute a breach of duty and reliance on expert evidence will be reduced in these areas.

There will also be a wider impact on consent allegations as the MCB references McCulloch and directs that women should be supported by clinicians to understand their options and the potential benefits, harms and consequences of each. This, in a small way, formalises the Supreme Court’s decision in McCulloch, and creates a guidelines for solicitors to refer to in respect of consent allegations.

While to a lesser extent, the MCB could also be used in causation arguments, as it was produced to lessen the risk of maternal death. In the future, the argument could therefore be made that “but for” the failure to implement the standards, the outcome would have been different. 

From a defendant perspective, where the standards are fully implemented by NHS Trusts and ICBs, there could be a fall in claims relating to the above high-risk areas. There is also the hope that the MCB will have its intended effect, and that earlier detection and management of risk will prevent patients suffering avoidable injury and death. 

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