On World Cerebral Palsy Day, I would like us to reflect on both the significant lifelong impact cerebral palsy has on children and their families, and also what healthcare systems can learn from the relatively small number of cases in which cerebral palsy results from avoidable harm during birth.

Earlier this year, the Supreme Court handed down an important judgment in CCC v Sheffield Teaching Hospitals NHS Foundation Trust [2026] UKSC 5. The case concerned a child who sustained a severe hypoxic brain injury during birth, resulting in severe cerebral palsy and a substantially shortened life expectancy.

The clinical negligence causing her injury had been admitted. 

The issue before the Supreme Court was instead whether a child whose life expectancy had been shortened by negligence can recover damages for the earnings and other financial losses they would have sustained after their likely death — the so-called “lost years”.

By a majority of four to one, the Supreme Court held that they could. In doing so, it overturned the longstanding Court of Appeal authority of Croke v Wiseman, which had prevented such awards being made to young children. 

The legal significance is considerable, but for those of us working on the frontline of maternity care, the circumstances underlying the case should also prompt reflection.

Looking beyond the value of a claim

Nearly a decade ago, during my Darzi Fellowship at NHS Resolution, I authored Five Years of Cerebral Palsy Claims, a thematic review of 50 cerebral palsy claims in which legal liability had been established.

As many would have predicted, the commonest theme related to fetal heart rate monitoring in labour. I am not going to discuss the pros and cons of the tool itself here, however, importantly the report cautioned against seeing these events simply as failures by individual clinicians to correctly interpret a CTG.

For those of us who make these clinical decisions know, the underlying causes were frequently more complex and multifactorial.

Failures in situational awareness, escalation, communication and teamwork all featured. Fetal monitoring could sometimes be considered in isolation rather than as one component of the wider assessment of the mother and baby. The report therefore argued not solely for more CTG training but for multidisciplinary training which combined technical knowledge with leadership, teamwork, communication and an understanding of human factors.

Those observations remain relevant when considering cases such as CCC.

When a baby sustains a hypoxic brain injury during labour, it can be tempting retrospectively to identify a particular CTG, decision or clinician as the point at which something “went wrong”. Sometimes there will indeed be a clear individual error, but effective learning requires us to ask a wider question: what were the circumstances that allowed that error to occur or prevented it from being recognised and corrected?

From “is the CTG OK?” to “is the baby OK?”

Cardiotocography remains an important tool in intrapartum care, but it is not a diagnosis. Nor should our objective simply be to decide whether a CTG fits within a particular category.

A much more clinically meaningful question is: “Is the baby OK?”

That apparently simple change in emphasis is important. The CTG is one source of information about fetal wellbeing. It needs to be considered alongside the trajectory of the trace, labour progress, maternal observations, antenatal and intrapartum risk factors, medication, meconium, uterine activity and the wider clinical picture.

This principle sits well with the direction being taken by the RCOG, Royal College of Midwives and THIS Institute through the Avoiding Brain Injury in Childbirth (ABC) programme. Its work on recognising and responding to suspected fetal deterioration seeks to integrate intrapartum risk factors into a more standardised approach to assessment, decision-making and action, rather than viewing CTG interpretation in isolation. This is a welcome development.

CTG interpretation has an inherent degree of subjectivity. Seemingly ever-changing classification systems cannot, by themselves, remove that subjectivity. What may make a greater difference is helping clinicians structure their thinking around what the information in front of them means for the individual baby, how that assessment is changing over time, and what response is required.

The ABC programme also recognises something repeatedly identified in reviews of maternity harm: safe fetal surveillance depends on more than an individual’s ability to interpret a trace. Teamwork, communication, escalation and coordinated action are equally important.

When concern develops, therefore, the relevant questions extend beyond the CTG. Is there a clear route for escalation? Is senior review genuinely accessible? Do team members feel able to challenge a decision? Does the clinician reviewing the trace understand how it has evolved over the preceding hours rather than simply assessing a short snapshot? And, once a decision to expedite birth is made, can the multidisciplinary team deliver that safely and promptly?

The hope is that programmes such as ABC will help move us further away from fetal monitoring as an exercise in classification and towards a shared multidisciplinary assessment of a much more important question: is this baby showing evidence that it may no longer be coping with labour, and if so, what are we going to do about it?

Documenting not just the decision, but the thinking behind it

There is another lesson I have increasingly taken from reviewing adverse maternity events and, more recently, cases that have progressed to litigation.

Clinical records often tell us what decision was made, but not why it was made.

An entry might record that a CTG was reviewed and that labour should continue, or that birth should be expedited. What is frequently missing is the clinician’s overall impression: what they thought was happening physiologically, which features of the trace or wider clinical picture concerned or reassured them, how they balanced competing factors, and why those findings led them to the plan they chose.

At the time, the reasoning may have seemed obvious. Several years later, when the same decision is being examined during a serious incident investigation or litigation, it may be anything but. It is not uncommon for two appropriately competent clinicians to come to different opinions or management strategies for the same clinician scenario or when reviewing the same CTG trace. The important question is therefore not always simply whether another clinician, with the benefit of hindsight, would have made exactly the same decision but whether the thought process that took clinician A down one route versus the route chosen by clinician B was valid, clinically sound and in terms of litigation, reasonable. Understanding how the clinician arrived at that decision can be equally important;

Was the CTG considered in the context of the whole clinical picture? Were relevant risk factors recognised? Was the evolution of the trace considered? Was an alternative explanation considered? Was appropriate escalation undertaken? Was there a clear plan for reassessment if the situation changed?

In my experience of reviewing cases, a short contemporaneous entry explaining the ‘clinical impression’ can be enormously valuable. It demonstrates clinical reasoning rather than simply recording an outcome.

There is an important patient-safety benefit too. Explicitly articulating an impression encourages clinicians to synthesise the information in front of them. Writing, for example, what do I think is happening, why do I think it, and what am I going to do about it? creates a natural opportunity to reconsider whether the proposed plan remains appropriate. Not only that, it helps others looking after the patient understand why decisions were taken in the first place and puts these into context. 

Good documentation should therefore not be regarded primarily as defensive medicine. It is part of good clinical decision-making.

And years later, if care is scrutinised, those few sentences may provide something that no retrospective expert analysis can recreate with certainty: what the clinician actually thought at the time.

Litigation as a source of learning

There is another important lesson from CCC. Clinical negligence litigation and patient safety are sometimes treated as separate worlds. They should not be.

Claims represent a unique source of patient-safety information. By the time a cerebral palsy claim is resolved, evidence may have been examined in extraordinary detail: clinical records, fetal monitoring, witness accounts and expert opinion. Viewed collectively rather than individually, claims can reveal recurring patterns that may not be apparent from local incident reporting alone.

That was one of the central principles behind Five Years of Cerebral Palsy Claims: litigation data should not simply be regarded as a financial liability. It should be used as a learning resource.

The Supreme Court’s decision potentially increases the financial consequences of some catastrophic injury claims because children with a shortened life expectancy are no longer excluded in principle from recovering losses relating to their lost years. But the financial consequences should never become the principal reason for improving maternity safety. Behind every multimillion-pound cerebral palsy claim is a child and a family whose lives have been fundamentally altered. Compensation is essential where negligent care has caused injury, but no financial award can restore the life that family expected. As the late Professor Tim Draycott used to say, ‘this is money that no one ever wants to receive’. 

The strongest argument for prevention therefore remains the human one.