Decision Report 201405452

Summary

Mrs C was unable to eat or drink without being sick in the early weeks of her pregnancy, and she complained that a midwife should have taken a urine sample for testing to look into this problem. Mrs C also felt unwell in the weeks following her return home after giving birth. Mrs C said the midwife incorrectly told her that a urine test result for infection was negative, when she was later told by a doctor that the result was not ready on the day the midwife spoke to her, and it turned out to be positive for infection. In addition, Mrs C complained about the board’s handling of her complaint.

We looked at Mrs C’s records and took independent advice from one of our nursing advisers. We found that the records made by the midwife were minimal and not accurate, and we noted the board’s acknowledgement that this was not a standard of care they would expect to see. We upheld this part of Mrs C’s complaint.

In their written response to Mrs C, the board acknowledged that the experiences with the midwife had caused Mrs C distress, and that there had been miscommunication and failures in record-keeping, for which they apologised. While we had some criticisms, which we made recommendations to address, we decided on balance that the board’s handling of Mrs C’s complaint was adequate and we did not uphold this part of Mrs C’s complaint.

Recommendations

We recommended that the board:

• provide us with evidence of the feedback given to the midwife involved and community midwives in general, and of how the issues around communication, planning and documentation have been addressed;
• ensure that references to the content of clinical records in written complaint responses accurately reflect the records; and
• ensure that discussions with relevant staff as part of complaints investigations are documented and included in the complaint file.