Neonatal hypoglycaemia - 15 years of claims under review

In the first few days after birth, before regular and adequate feeding is established, babies often need help with managing their blood glucose levels. Newborns with low birth-weights (below 2.5kg) or those born to diabetic mothers are at increased risk of developing neonatal hypoglycaemia (low blood glucose). However, any baby who isn’t feeding properly  – not waking for feeds, not sucking properly, or is demanding very frequent feeds –  may be at risk. 

Where neonatal hypoglycaemia is associated with abnormal clinical signs –  such as hypothermia, floppiness, jitteriness or fitting, infection or respiratory difficulties –  it should be regarded as a clinical emergency. If the risk factors or clinical signs are not recognised and the baby’s blood glucose levels are not monitored and adequately maintained either by feeding or intravenous glucose, the baby can suffer permanent injury to their brain, leaving them with lifelong, severe, neurodevelopmental disability.

In its recent Annual Report NHS Resolution highlighted the extent of the damage caused to newborn babies by deficiencies in NHS management of neonatal hypoglycaemia over a 15 year period. A review of NHSLA’s settled neonatal hypoglycaemia cases revealed that 25 successful claims were brought by the families of babies born between 1995 and 2010, whose neurodevelopmental injuries were caused by avoidable neonatal hypoglycaemia. The total litigation cost to the NHS (including damages and the legal costs of both sides) was over £162 million. Given the severe injuries needed to justify such high claims, the lifelong ‘cost’ to the babies and their families will have been far greater than money could ever adequately compensate.

NHSLA (as it was at that time) co-authored an article with NHS Improvement which was published in the BMJ, Neonatal hypoglycaemia: learning from claims, in which they shared the findings of their review with the medical profession. Whilst emphasising that “cases of neonatal hypoglycaemia sufficiently severe to cause brain injury and resulting in litigation are rare”, they used the data from these claims to illustrate that despite the existence of teaching texts and guidelines, deficits in clinical care are resulting in delayed diagnosis and management of neonatal hypoglycaemia, at enormous financial cost to the NHS.

Their findings revealed that the claimant babies were all born at 36weeks or later gestation. 57% of the babies had a birth weight of 2.5kg or less, the standard threshold for initiating blood glucose monitoring. However, NHSLA noted that babies born at more advanced gestation who were over the weight threshold could still be at risk of hypoglycaemia, particularly if they were small for dates with intrauterine growth retardation (IUGR).

The most common reported signs were abnormal feeding behaviour. Poor feeding can be both a cause and a consequence of hypoglycaemia, but is very strongly associated with the condition. Eight of the babies with no other obvious causes for hypoglycaemia presented with abnormal feeding behaviour. NHSLA pointed out that in many of the cases the mother had repeatedly raised concerns, which were not acted upon by the midwives. Sadly, in many of the cases that we take on, the mother is the first to recognise that the baby is unwell but instead of her concerns leading to further investigation which might reveal the problem in time for remedial treatment, she is inappropriately reassured and the opportunity to avoid the damage is lost. NHSLA recommended that maternal concerns, particularly with regard to feeding, should not be discounted, but should be followed by a detailed history and assessment of the baby’s condition.

Another common sign was hypothermia. In fact, in addition to low birthweight, almost all the claimants had abnormal feeding behaviour or hypothermia prior to their diagnosis of hypoglycaemia.

Two of the babies had been born to mothers with gestational diabetes. One baby had septicaemia, and another had hyperinsulinism (unusually high levels of insulin in the blood), both of which were serious conditions but were present before the hypoglycaemia was diagnosed.

In reviewing the 25 cases which gave rise to successful claims, NHSLA identified common deficits in care:

• Delay in acting on a low blood glucose result
• Delayed referral to a paediatrician after concerns were identified
• Delayed admission to the neonatal unit following the diagnosis of clinically significant hypoglycaemia
• Delayed admission of intravenous glucose after admission to the neonatal unit
• Administration of insufficient glucose to correct the hypoglycaemia
• Delayed attendance by the paediatrician in response to the midwife’s request
• Delay in obtaining the result of the blood glucose test
• Failure to give appropriate advice to the mother when the baby was discharged home.

Having shared what happened in these cases and highlighted the risk factors and clinical signs to be heeded and the failings that give rise to injuries and claims, NHS Resolution recommend that the learning from these devastating injuries will be used to reduce further harm and divert NHS funds from litigation to patient care.

At Boyes Turner, our brain injury lawyers are experienced in recovering compensation awards for children with neurodevelopmental injury caused by avoidable neonatal hypoglycaemia. Our client families come to us at various times during their children’s childhood, some as babies immediately after the injury, others following diagnosis of brain injury on an early MRI brain scan, others as the children grow and begin to recognise the extent of their injury as they experience difficulties at school.