Decision Report 201302662

Summary

Mr C complained on behalf of his wife (Mrs C) about the care she received from the maternity triage service at Forth Valley Royal Hospital immediately prior to the birth of her daughter. Mrs C had phoned the service twice for advice about coming into hospital as she was concerned about the progress of her contractions, and felt she was dissuaded from going to hospital after speaking to a midwife during her second phone call. Around an hour later, Mrs C gave birth to her daughter at home with the assistance of her husband. She suffered heavy blood loss, paramedics attended and she was transferred by air ambulance to another hospital.

We took independent advice on this case from one of our medical advisers, who is a specialist in midwifery. Our adviser was critical of the midwife's actions during the second phone call, as they should have asked Mrs C to attend hospital for assessment of whether or not she was in active labour, given that she had experienced complications during a previous birth. We also found that the maternity triage phone template did not prompt staff to ask women about their previous medical history. We, therefore, upheld Mr C's complaints about the advice Mrs C had received by phone, and the lack of adequate documentation of the advice given.

In responding to Mr C's complaints, the board agreed to make triage staff aware that patients should not feel as if they need permission to attend hospital, and acknowledged that the midwife had not documented any advice she had given Mrs C about coming into the hospital. They also took steps to introduce a new national maternity triage template to ensure that appropriate information is captured, and introduced peer review.

Although we took the view that the board made reasonable improvements to shortcomings in the triage process, we did not find that the structure in place at the time was inadequate. We also concluded that it was not unreasonable for the board to have staffed the maternity triage service with a labour ward midwife, given they are qualified to determine if admission is necessary or not. We did not uphold those aspects of Mr C's complaint.

Recommendations

We recommended that the board:

• ensure that the midwife reflects on our adviser's comments as a learning tool;
• ensure midwifery triage staff appropriately document advice they provide; and
• apologise to Mrs C for the failings our investigation identified.