On 19 March 2025 Kennedys' global healthcare team hosted their global maternity indemnifiers conference.
We welcomed indemnifiers and senior clinicians from Australia, England, Germany, Hong Kong, Ireland, Japan and Sweden, who shared their perspectives on best practice, their experience and innovation in relation to improving response to and prevention of harm within maternity care.
Indemnifiers have a rich source of information which can be thematically reviewed to facilitate learning from claims and improve patient safety. Indemnifiers around the world are making a unique contribution to learning from claims and improving the wider system, particularly in relation to maternity care.
We hope that with so many distinguished speakers, healthcare professionals, indemnifiers from around the world all sharing their experiences and innovations, that we have genuinely made a difference to improving maternity care.
Here we provide an overview of some of the key areas of discussion from the conference.
Christopher Malla, Global Head of Healthcare
Australia
Angela Kelly, Chief Insurance Officer, Victoria Managed Insurance Authority (VMIA) provided an indemnifiers perspective, sharing insights into the maternity litigation landscape in Australia, in particular in the State of Victoria, and some of the programmes the VMIA invests in to help prevent harm and reduce claims.
The two key functions of the VMIA (the Victoria government's insurer) are to provide insurance to government enterprises in Victoria, and risk advice to the government and its departments and agencies.
Angela explained that over the last 18 years the VMIA has seen a significant reduction in maternity claims, particularly claims associated with hypoxic brain injuries. Following the introduction of the Fetal Surveillance Education Program in 2006 and PROMPT (practical obstetric multi-professional training) in 2013 the incidence of obstetric claims reduced by 60% in the 10-year period between 2006 and 2016.
To help sustain practice of the PROMPT program the VMIA developed the Incentivizing Better Patient Safety Program. This includes incentivizing hospitals to train 80% of their birth suite clinicians in three areas – multi-professional emergency training, clinician surveillance training and embedded processes for escalation, and neonatal resuscitation. If hospitals can demonstrate they have achieved this at attestation, the VMIA provide a premium refund of 5% of the obstetrics component of the premium. The VMIA is now looking to use this incentivisation program to implement and support other quality, safety and best practice programs in maternity.
Hong Kong
Professor Tak Yeung Leung, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong provided insights into several factors that can contribute to poor outcomes in maternity care.
Among the key issues discussed, Professor Leung explained that mode of delivery and fetal wellbeing often feature in maternity care complaints in Hong Kong.
By way of example and in the context of delivery complicated by shoulder dystocia, Professor Leung explained that this can arise where incorrect methods are taught, as well as limitations with the training apparatus which mean that not all can demonstrate the appropriate manoeuvre correctly.
In relation to fetal wellbeing, Professor Leung explained that fetal hypoxia or fetal distress can be missed where the maternal pulse is mistakenly identified as the fetal pulse. This, Professor Leung explained, can occur because the abdominal detector for a CTG - intended to detect the fetal pulse - also detects the maternal pulse from the aorta due to the fetal pulse being very weak.
In relation to private practice, Professor Leung identified movement of practitioners between hospitals as a factor that often limits the opportunity to establish teamwork.
Japan
In conversation with Cindy Tucker, Partner in our Melbourne office, Professor Shin Ushiro, Board Member of the Japan Council for Quality Health Care (JQ) and Deputy Director of Kyushu University Hospital discussed Japan's obstetric compensation scheme for cerebral palsy.
Launched in 2009, the no-fault compensation scheme is operated by JQ. Professor Ushiro explained the system has two functions – the provision of compensation on a no fault basis and an investigation, prevention and learning program.
JQ has published almost 4,000 investigative reports. Collective analysis of the investigative reports enables the production of a prevention report on an annual basis, setting out learnings and is circulated among professional and scientific bodies, and studied at an annual conference of those bodies.
The reports are highly valued and respected, including by the courts. They are produced by multiple professionals in the presence of plaintiff and defendant lawyers and finalised by an investigative committee joined by patient representatives.
Embedded in the system, patients and family representatives are involved from the early stages. The scheme recognises the importance of the patient and family voice.
England
Helen Vernon, Chief Executive of NHS Resolution underlined the important role that indemnifiers have in highlighting safety issues in maternity care.
NHS Resolution has maternity as a standalone strategic priority.
At a local level NHS Resolution's safety and learning team work very closely with NHS providers to understand their claims risk profiles to better target their safety activities. Then at a macro national level sharing learning across the system through events, resources and partnership working.
Among the key areas discussed were the following two initiatives.
Early Notification Scheme (ENS)
Introduced in 2017, ENS aims to bring a more rapid, caring response to families whose babies may have suffered severe harm. Requiring early reporting of incidents which meet specific clinical criteria, the scheme aims to improve the experience for the family and affected health care staff, and to share learning rapidly with the individual trust and the wider system to prevent the same things happening again.
Through the scheme much earlier admissions of liability have been achieved, with earlier support for staff and families including interim payments, and the surfacing of safety issues and integration of learnings from those.
ENS continues to test ways to change and challenge the traditional model for resolving high value compensation claims.
The Maternity Voices Advisory Group has been established to provide external stakeholders and in particular families and their representatives with a forum in which they can advise and support future developments to the ENS. A family liaison and mediation team, and a professional language service provide support to families.
Maternity Incentive Scheme (MIS)
The scheme supports the delivery of safer maternity care through the introduction of an incentive element into NHS Resolution's pricing for providers. The scheme is overseen by a cross-system advisory group and rewards trusts that meet ten core safety actions designed to improve the delivery of best practice in maternity and neonatal services.
NHS Resolution is in the process of evaluating the scheme, with the findings to be reported on later in 2025. So far, the evaluation is showing that MIS is a key driver for elevating maternity safety discussions at board level.
Professor Tim Draycott, Senior Obstetric Adviser, NHS Resolution discussed the work that NHS Resolution has undertaken with THIS Institute to identify what makes a maternity unit safe. Explaining that it is the social, organisational and cultural factors, staffing levels, the physical environment and local multi-professional training.
The data NHS Resolution has and is utilising is central to the work it is doing to improve safety in maternity services.
Observing that incentivisation improves the number of safety actions people achieve, Professor Draycott emphasised that the key issue is whether the safety actions are appropriate.
Demonstrating the work indemnifiers can do at system levels to help facilitate positive change, Professor Draycott highlighted the Avoiding Brain Injury in Childbirth programme.
Looking ahead, Professor Draycott explained that consideration needs to be given to how improvements can be made to supported decision making, recognition and then the response to this. Identifying personalisation of care as a significant challenge for maternity services over the next decade, Professor Draycott highlighted the role that artificial intelligence could play in helping in this regard, to prevent both over and under-intervention.
Sarah Land, co-founder of PEEPS (the only UK charity dedicated to supporting those affected by Hypoxic Ischaemic Encephalopathy (HIE)) provided a parent's perspective, sharing family perspectives from experiences with children with HIE.
Sarah founded PEEPS with her husband following their own experience of HIE with their daughter, Heidi.
Among the key matters Sarah discussed is the importance of family-oriented care. This means having the families at the heart of everything whether that is during pregnancy, childbirth, postpartum, neonatal care or palliative care - involving families in all decisions, speaking to them, and giving them time and choices.
Sarah emphasised how important it is for families to feel they are part of the decisions and the need for open channels of communication, and managing expectations. This will look different for each family.
Among other key matters discussed, Sarah spoke about trauma informed care, highlighting the need to recognise the trauma families have been through, the psychological impact that can have and the importance of not compounding that.
Professor Jane O'Hara, Director of Research at THIS Institute spoke about research into involving patients and families compassionately when harm events have happened in healthcare.
Professor O'Hara observed that traditionally, patients and families have not been involved in investigations.
Explaining there is a huge amount we can learn from patients and families, Professor O'Hara emphasised the importance of recognising that learning from incidents is not the only outcome they need. Patients and families have a range of needs, and failing to meet these can result in compounded harm. Healing is a profound need from investigations. Listening and supporting must underpin everything.
Patients and families can tell us a huge amount about unsafe conditions - issues that are likely to lead to future healthcare harm or error.
Dr Denise Chaffer, former Director of Safety and Learning, NHS Resolution discussed the staff experience in relation to maternity claims and shared insights on effective leadership in healthcare organisations and embedding a just, learning and restorative culture for all.
In the context of reviews into maternity care in recent years, Dr Chaffer considered what can be done in the UK to help build trust and confidence for all, and improve retention of staff.
Highlighting the importance of partnership and collaboration and observing that common to all reviews and reports that follow is the wealth of recommendations, Dr Chaffer emphasised the need to move into the 'how' space in the improvement journey.
Among the actions required to support this is prioritisation of what needs to be done via a thematic approach and measurement of impact, addressing contributory factors for retaining staff, and investment in compassionate leadership development at all levels.
Dr Chaffer also explained that continued work is required on providing support to families and what a meaningful apology really looks like, and empowering staff in resolution.
Professor Dame Lesley Regan, Professor of Obstetrics and Gynaecology at Imperial College's St Mary's Hospital Campus, and Honorary Consultant at the Imperial College NHS Trust, and Women's Health Ambassador for England, provided her reflections on maternity care.
Among the key areas discussed, Dame Lesley highlighted the need to think about women's health across the entire life course and to reflect on the importance of understanding what role maternity and pregnancy plays across a woman's life.
Reflecting on the large number of previous reviews, and anticipated future reviews into maternity care, Dame Lesley expressed the need to shift the approach away from reviews to one of accelerating action to change the outcome, assessing the impact, and collaboration.
Ireland
Dr Cathal O'Keefe, Deputy Director – Head of Clinical Risk at the State Claims Agency (SCA) in Ireland provided the perspective of an indemnifier.
The SCA is responsible for the management of clinical and non-clinical claims and allied to that is its risk management function, and a legal costs management unit. The SCA's mandate is essentially to identify, analyse and understand risk, and to provide advice to health and social care providers.
The Clinical Risk Unit of the SCA uses data – from the national incident management system, which all health and social care authorities are required to report adverse incidents, and claims data to - to inform its risk management activities and providing the ability to detect trends that may be occurring nationally.
Dr O'Keefe shared insights into the work of the National Neonatal Encephalopathy Action Group (NNEAG). Established to identify issues resulting in adverse outcomes for newborns and to develop measures to mitigate those risks, NNEAG is a collaborative approach between the SCA, the Department of Health, the National Women and Infants Health Programme (NWIHP), and the Health Service Executive (HSE).
NNEAG led to the establishment of the Obstetric Event Support Team (OEST), to bring objectivity to the reviews in maternity units in relation to incidents resulting in significant injuries to the baby or mother. The team consists of a consultant obstetrician, midwife and a patient safety lead. Findings are used by NWIHP in an aggregated form to identify common themes emerging and drive educational and other activities. OEST is now embedded in the work of HSE.
Germany
Professor Constantin von Kaisenberg, Consultant Obstetrician and Head of PROMPT Germany, provided insights on how the implementation of PROMPT (practical obstetric multi-professional training) has and continues to help make significant improvements in maternity care and outcomes.
Professor von Kaisenberg discussed the main components of effective training – including evidence, authenticity of training materials, multi-professional (those who work together train together), and annual participation. This approach has seen substantial improvement in teamworking, communication and professional satisfaction.
The next steps include creating incentives and financing of in-house courses. Other options include exploring a deduction from the insurance malpractice premium subject to annual participation in effective multi-professional training reaching a certain level.
Sweden
Dr Charlotte Elvander, Midwife and Vice President of the Swedish Association of Midwives discussed the use of the Swedish Pregnancy Register and the Swedish Pregnancy Survey for data-driven quality improvement, and factors contributing to good outcomes.
The Swedish Pregnancy Register - a national quality register launched in 2014 - collects information from pregnancy, during birth and post-partum, and is updated daily. Every doctor and midwife in the country can access the system and see the data for each unit and each region. An annual report summarises the data from the different maternity wards in Sweden, bringing transparency.
Recognising the importance in assisting with quality improvements, pregnancy related experience and outcome measures questions have been part of the register since 2020.
Dr Elvander observed that good access to reliable, transparent data not only supports better decision-making but also highlights best practice and enhances accountability.
Dr Elvander also discussed the importance of interprofessional collaboration and a holistic approach, including the role the physical environment of the birthing room has in supporting positive outcomes.
Dr Gustavson, Chief Medical Officer, Löf (the indemnifier for all regionally paid for healthcare in Sweden whether provided by a private or public care giver), provided insights into the approach taken by the indemnifier, which is a mutual insurer.
Dr Gustavson explained that if investigations identify a breach of good professional standards or the provision of care that is not in accordance with good Swedish healthcare then it is assumed that the injury could have been avoided and is compensated. The decision as to whether the injury was avoidable or not is made based on advice from medical advisors who are experienced specialists. Dr Gustavson explained (at the time of speaking) that a decision is made within approximately five to six months, which includes the investigation, and the indemnifier is striving to reduce this timeframe.
A preventative approach is taken, through collaboration with professional organisations, midwives, obstetricians, paediatricians and neonatologists to identify what they think is the problem, what Löf see as the problem, and what can be done collectively to prevent injuries from happening.
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