NHS Resolution’s report concludes the findings of its investigations into cases of babies born with a potentially severe brain injury following labour, at term, which were reported to the NHS body under a new Early Notification Scheme.

The scheme, in place since April 2017, aims to give families quick answers to questions about what may have gone wrong with the care they received, provide support and, if appropriate, award compensation without delay.

It is part of a government plan to halve rates of stillbirths, neonatal/maternal deaths and brain injuries linked with birth by 2025 and covers 129 trusts in England. The new report looked at 96 serious cases of 197 investigated for liability.

It found problems with checking fetal heart rates during labour was a factor in 70 per cent of cases, with delays in giving birth noted in 63 per cent of cases.

These included delays in transfers to labour wards, admission to theatres and pain relief administering. The report also warns that “immediate neonatal care and resuscitation remains an important but an under-recognised factor that limited support for staff and families not being involved sufficiently”.

Among several recommendations, it urges the implementation of “an evidenced-based, standardised approach to fetal monitoring in England”.

It says: “Effective improvement strategies for fetal monitoring require in-depth understanding of the social mechanisms underpinning the process, not just the technical issues. Research in this area should be prioritised urgently.”

It also calls for an increase in awareness of impacted fetal head and difficult delivery of the fetal head at caesarean section, including the techniques required for care.

“Research to understand the prevalence, causes and management of impacted fetal head is a priority, along with effective training in management techniques,” it says.

Other recommendations include open conversations with families about their care and the investigation process, support, including psychological assessment, for NHS staff and increased awareness of the importance of the resuscitation and immediate neonatal care for newborn babies.

Dr Samantha Steele, lead author and national obstetric clinical fellow at NHS Resolution, said: “Having a baby should be a positive experience for families but sadly things do occasionally go wrong in maternity care with devastating effects.

“By carrying out early liability investigations, we can improve the experience for families and staff affected, provide early support and reduce formal litigation in the courts and the associated legal costs. Proximity to incidents also enables time relevant learning to be identified and shared at a national, regional and local level.”

Gill Walton, chief executive of the Royal College of Midwives (RCM), said: “Every incident of avoidable harm leaves families devastated and affects midwives and maternity staff. Included in the report are recommendations around how women and their families are treated when things go wrong and also how staff can be supported which is something the RCM really welcomes. For the vast majority of women and their babies, the UK is a safe place to give birth. However, despite the fall in stillbirth and neonatal mortality, avoidable incidents do happen.

“We want women and their babies to receive the safest possible maternity care so it’s vital we enable learning for improvements to safety and to reduce avoidable deaths.”

Health minister for maternity and patient safety Nadine Dorries, said: “We’re determined to continually improve how we support affected families and ensure the NHS can learn immediate lessons to avoid future harm.”