Decision Report 201203181

Summary

Mrs C complained about a number of matters related to her caesarean section (c-section - an operation to deliver a baby, which involves cutting the front of the abdomen and womb) and her subsequent care. Mrs C experienced a combination of complications including heavy bleeding and deep vein thrombosis (DVT) requiring hospitalisation.

After taking independent advice from a medical adviser, we found that most of Mrs C's medical and nursing care was reasonable. However, we upheld her complaint as we considered that the board did not take all possible precautions to reduce the likelihood of her developing DVT and heavy bleeding. We identified that Mrs C was given a combination of drugs that was likely to have caused her bleeding to worsen. We also considered that Mrs C should have been given compression stockings before and after the c-section until she regained full mobility. This did not happen in line with national guidelines on thrombosis and embolism in pregnancy. Mrs C also developed pressure sores following her c-section - the board acknowledged that she had not been properly assessed in this respect and agreed that this was unacceptable.

Recommendations

We recommended that the board:

• provide evidence to show that they have updated their policy on DVT to include the use of compression stockings;
• provide evidence to show that they have reminded relevant staff of the importance of assessing those mothers at risk of developing pressures sores following c-section;
• consider developing a template for documenting pressure sore risk assessments; and
• apologise to Mrs C for the failings we identified.