Decision report 201102889

Summary
Ms C was pregnant. She went to hospital, where it was found that her waters had broken and she was booked in to be admitted the next morning for an induced labour. Ms C complained to us that on the day she was admitted she did not receive antibiotics until the evening. This was contrary to the board's own policy that if an expectant mother's waters had broken she should receive antibiotics immediately on admittance to hospital to reduce the risk of infection. We upheld Ms C's complaint that there had been a delay in administering antibiotics in her case. However we did not make any recommendations as we noted the board had taken steps to address this.

Ms C underwent a long labour, and had a epidural (an anaesthetic administered by a fine tube inserted into the spine, the effects of which come on gradually and continuously) which she told us became displaced and leaked. As Ms C's labour was not progressing, staff decided that she should go into theatre for either a forceps delivery or caesarean section. To prepare her for this, she was given a spinal block (a single shot spinal injection) for more rapid and profound analgesia. The anaesthetist had difficulty placing the block, and after several attempts called a consultant anaesthetist for assistance. The consultant also had difficulty placing the block although they eventually managed to do so. Having taken advice from one of our medical advisers who is a consultant anaesthetist, we did not uphold Ms C's complaint that an unreasonable number of attempts were made to insert the block. We found that the anaesthetist had acted correctly and called the consultant within a reasonable amount of time. We also found that given that both the anaesthetist and the consultant had had difficulties in placing the block, there were no training issues identified.

The block then worked very quickly, and Ms C developed numbness in her arms and chest and had breathing difficulties. After her daughter was born, Ms C had to be placed under general anaesthetic and on a ventilator until she was able to breathe unassisted again. Although we recognised how traumatic and frightening this had been for Ms C, we did not uphold her complaint about this, as we found that it was a rare but recognised complication of a spinal block. We also found that medical staff had acted appropriately, and had met Ms C later and tried to explain to her what had happened. As general medical understanding about this complication is limited, we found that they had explained it to the best of their abilities.

Finally, Ms C complained the board had not responded to her complaints adequately, especially her concerns about the future. We did not uphold this complaint. We found that the board had made efforts to discuss Ms C's continuing concerns about future pregnancies or procedures. We considered that their position that further tests would not add anything to their knowledge of Ms C was reasonable.