Decision Report 201601884

Summary

Mrs C complained about care and treatment she received during her pregnancy, delivery and postnatal period. Mrs C was unwell during her pregnancy and was latterly diagnosed with pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine) at the Southern General Hospital. She was transferred to the Royal Alexandra Hospital for a caesarean section as they had space available to care for her premature baby following delivery. Following the delivery, Mrs C was transferred to a maternity ward for around two days until her discharge home while her baby remained in the special care baby unit. Mrs C was seen by a community midwife at home and was subsequently readmitted to the Royal Alexandra Hospital where she was diagnosed with peripartum cardiomyopathy (a rare disease defined by heart failure towards the end of pregnancy or in the months following delivery). Mrs C was treated in the cardiology department before being transferred back to a maternity ward. While she remained in hospital, Mrs C experienced severe abdominal pain and a scan revealed that she was suffering from retained placental tissue (a condition where parts of the organ attached to the lining of the womb during pregnancy remain following birth). A procedure was carried out to remove these.

Mrs C had a number of concerns about her care and treatment and complained to the board. She complained that there had been unreasonable delays in diagnosing her with pre-eclampsia, peripartum cardiomyopathy and retained placenta. She further complained that she was discharged too early, that the placenta had not been removed during the caesarean section, that she was unreasonably encouraged to express breast milk, and that staff had not treated her compassionately. The board responded to Mrs C's concerns in writing and also arranged meetings with her to discuss her experience. Mrs C was unhappy with the board's handing of her complaints, and she brought her concerns to us for further investigation.

We took independent advice from a midwifery adviser and a consultant obstetrician during our investigation. We found that there had been no delay in diagnosing Mrs C's pre-eclampsia or peripartum cardiomyopathy, and that, taking her clinical records from that time into account, her discharge was reasonable. In relation to Mrs C being encouraged to express breast milk, our midwifery adviser highlighted no concerns. We did not uphold these complaints as a result.

We did, however, find that the placenta had not been fully removed during the caesarean section and that the risks of needing a further procedure (such that to remove retained placenta) had not been mentioned on the associated consent form. The obstetrics adviser highlighted concerns about the subsequent procedure to remove the retained placenta and pain that Mrs C suffered. We upheld Mrs C's complaints about the retained placenta and noted that the board had already offered apologies for the delay and pain she experienced. We made further recommendations in relation to these issues. We also upheld Mrs C's complaint about her treatment by staff. While the advice we received did not highlight any concerns about communication, we noted that, during their own investigation, the board apologised for poor attempts at humour on the part of a staff member and advised that Mrs C's experience would be used as a reflection and learning exercise. We made a recommendation about this.

Mrs C also complained about the way that the board had handled her complaint. We identified an issue in the way that the board determine the age of a complaint, however, this did not have a significant impact on their handling of Mrs C's case. We drew the board's attention to this but did not uphold this part of Mrs C's complaint.

Recommendations

What we said should change to put things right in future:

• Staff should be familiar with the Royal College of Obstetricians and Gynaecologists (RCOG) guidance on the consent process for caesarean sections.
• Staff should provide patients with sufficient information to allow them to make informed choices about their treatment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.