Decision Report 201204367

Summary

Ms C went into premature labour and was taken to Aberdeen Maternity Hospital as an emergency. She said that, after admission, staff failed to manage her labour and delivery properly, as a consequence of which her daughter was deprived of oxygen and suffered serious brain injury. Ms C also said that when she made a formal complaint about this, the board failed to deal with it properly.

During our investigation, we took into account all the relevant documentation, including the complaints correspondence and the clinical records. We also took independent advice from a consultant obstetrician and an experienced midwife.

We upheld Ms C's complaints. We found that the board delayed in dealing with Ms C's complaint, and that the evidence showed that her labour was not managed reasonably, as there had been some delays by nursing staff in seeking medical assistance and Ms C should have been transferred to a labour ward earlier than she was. However, despite these failings, we found no evidence to suggest that Ms C's baby should have been delivered sooner, or that care was compromised.

Recommendations

We recommended that the board:

• apologise for the shortcomings identified by the investigation and in particular that they did not keep Ms C updated about her daughter and failed to change her soiled bed;
• remind staff of the necessity and importance of keeping accurate and timely records and of their responsibility for signing them and detailing the reasons for any amendments. Midwifery staff should also be reminded of the NICE Clinical Guideline 5 and Nursing and Midwifery Guidance;
• provide details of the action they have taken in order to resolve the communication issues which existed and which were acknowledged by the chief executive; and
• remind staff of the necessity of adhering to their stated complaints policy.