Decision report 201201918

Summary

Mrs C, an advocacy worker, complained on behalf of Mrs A. Mrs A had given birth to her third child twelve days after the date on which the baby was expected. The board said that before the birth, Mrs A had only minor problems and so she was on a low risk pathway. The plan was for the baby to be born with the use of an epidural (spinal pain relief) but as labour progressed, the baby began to show significant distress and so was delivered by caesarean section under general anaesthetic. Within a few minutes, Mrs A began to suffer heavy bleeding, and needed a hysterectomy (surgery to remove the womb) to control this. Unfortunately, during this procedure Mrs A suffered damage to her urinary system, which needed further surgery. She had a slow recovery and was not discharged home for several weeks. Mrs C said that Mrs A suffered psychologically because of these events and that not enough was done to prevent them from happening.

Our investigation took into account all the available information, including the complaints correspondence and the relevant clinical and nursing records. We obtained independent advice from relevant consultants in all the areas relating to Mrs A's concerns, and from a senior matron in a maternity unit.

The board had sympathised with the difficult time Mrs A experienced and had apologised that aspects of her care had caused her concern. They acknowledged that the events of the delivery and what had happened after it had been difficult for Mrs A, but said they were of the view that everything that had been done had been in the best interests of her and her baby.

We did not uphold Mrs A's complaints about her care and treatment before and during the birth. We found that the clinicians involved in Mrs A's case had done nothing that contributed to her serious and life threatening condition. Our advisers said that all the procedures carried out were reasonable and had been appropriately administered. Although Mrs A felt that her husband had not been properly updated about her condition we concluded that this was reasonable, as the clinician's first responsibility had been to save Mrs A's life.

Overall, we found that Mrs A's care was generally reasonable. However, one of our advisers said that, once Mrs A was returned to a ward, it would have been appropriate to reassess her situation with regard to transferring her to a single room, particularly in view of her prolonged stay in hospital. The adviser also noted that an error was made with an injection and that Mrs A had been discussed publicly. These things should not have happened. We, therefore, upheld her complaint about the care she later received in the maternity ward and made recommendations to address this.

Recommendations

We recommended that the board:

• apologise to Mrs A for their shortcomings in this matter;
• emphasise to staff the importance of ensuring that discussions between professionals about an individual's care needs are kept private; and
• remind nursing staff to take account of individual patients' needs when allocating single rooms.