Decision Report 201204083

Summary

Mrs C complained about several aspects of her hospital care and treatment immediately before, during and immediately after the birth of her son. Mrs C's son was born by a forceps delivery which necessitated an episiotomy (a minor surgical cut that widens the opening of the vagina during childbirth). She also suffered a third-degree tear (a serious tear between the vagina and anus). She suffered a major haemorrhage (escape of blood) minutes later and required extensive life-supporting treatment. Mrs C was concerned that the complications she suffered might have been the result of poor care and treatment. She was also concerned that she and her husband were unsupported after such a traumatic experience and that this was causing her long-term health problems.

After taking independent advice from one of our medical advisers, our investigation found that while Mrs C had undoubtedly had a very traumatic and difficult birth experience, it was not caused by poor care or inadequate treatment. We were, however, very critical that the need to refer her to counselling services was noted in the post-natal ward but not acted on. This meant that Mrs C and her husband were not properly supported after the birth. We upheld this aspect of her complaint and made recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C and her husband for the failure to refer her for appropriate counselling while she was in the post-natal ward; and
• review the failure to refer Mrs C to counselling services and identify any improvements that can be made to the referral process in the future.