Decision report 201104444

Summary

Ms C was in the later stages of her first pregnancy, and was expecting twins. She went to hospital because she had vaginal bleeding. She was admitted for a consultant review and discharged home the following morning. Six days later she went into advanced labour and delivered both babies, but one of her twins died shortly after birth. Ms C complained to us about her care both before and after the birth.

Ms C's complaint had several elements, including inadequate care of a pre-eclampsia risk (a condition involving a combination of raised blood pressure and protein in the urine); inadequate care during two admissions which she said resulted in the premature birth of her twins and the death of her son; inadequate care and treatment for a post-natal haemorrhage (bleeding) and subsequent removal of products; poor record-keeping and delays in holding a clinical risk review (CRR).

Our investigation included taking independent advice from one of our medical advisers. We took account of this advice along with all the evidence provided by Ms C and the board, which included an internal report and two externally commissioned consultant reviews. Our investigation found no evidence of any failure that resulted in Ms C giving birth prematurely or any failure in care that resulted in the death of one of Ms C's twins. We also did not find any evidence of clinical failure with Ms C's post-natal care, but we did acknowledge that there were documentation failures and delays in holding the CRR.

Recommendations

We recommended that the board:

• ensure that the details of a speculum examination are fully documented to include the reasons if a cervix cannot be visualised and the rationale with regard to antenatal corticosteroids; and
• ensure the full documentation of all treatments delivered to patients is appropriately and timely recorded by those in attendance as soon as is feasibly possible, with specific reference to emergency situations.