Decision report 201001927

Summary
Mrs C raised concerns about the treatment she received at a hospital before and after the stillbirth of her daughter. These included an incorrect decision to reduce Mrs C's medication; a lack of support from midwifery staff; and that the board's response to her complaint contained factual inaccuracies. Mrs C also told us that she believed the reduction in medication had caused the stillbirth. When we investigated and took advice from our medical adviser we found that in general Mrs C's pregnancy was managed appropriately, but that there were problems after a doctor misinterpreted a blood test result. We upheld all of Mrs C's complaints, although our adviser pointed out that research did not support the view that a reduction in medication would cause stillbirth. We noted that the board had already accepted that there were failings and had taken action in an effort to prevent any repetition of Mrs C's experience. As a result of our investigation, however, we considered it appropriate to make further recommendations.

Recommendations
We recommend that Fife NHS Board:
• consider, when confirming blood results that have been passed on by telephone, providing additional confirmation such as an internal email or fax; and
• remind staff of the need to provide patients with information about support services and to record what has been provided.