Decision Report 201402424

Summary

Ms C complained that, during her pregnancy, the board failed to give her reasonable care and treatment and that there was a failure to diagnose placental insufficiency (a complication in pregnancy where the placenta is unable to deliver an adequate supply of nutrients and oxygen to the fetus), or that her baby was too small. Ms C's baby was stillborn.

We took independent medical advice from a consultant obstetrician, who told us that while ultrasound (a scan that uses sound waves to create images of organs and structures inside the body) provided the best estimate of fetal size, unfortunately it was not always accurate. Other tests (including measurements of the abdomen and blood flow in the umbilical artery) did not always pick up that a baby was small. Scans and other tests were also used to detect problems with the placenta but again were not foolproof. In Ms C's case, as she had already had two healthy births and had no apparent risk factors, all appropriate and reasonable steps were taken to properly monitor her pregnancy. While our adviser noted that with earlier delivery the baby would likely have survived, there was no indication for her to have been delivered earlier. Based on the evidence, we did not uphold Ms C's complaints about her care and treatment.

Ms C also complained about the way her complaint was handled. We upheld this complaint, as we found that there had been numerous delays, and that these had added to her distress.

Recommendations

We recommended that the board:

• make a formal apology for their delay and for any further distress caused; and
• remind those staff involved in responding to complaints (including any clinical staff) of the necessity of providing timely replies and demonstrate to us how this was done.