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Decision Report 201800304

  • Case ref:
    201800304
  • Date:
    October 2018
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained about the care and treatment she received at Royal Alexandra Hospital following the birth of her daughter. Ms C felt that staff did not provide her with advice on breastfeeding techniques. She also raised concern that staff denied her a medical review, despite the fact that she felt she had suffered a lot of blood loss. As a result of her dissatisfaction with the care provided, Ms C discharged herself from hospital against medical advice and put her care in the hands of the community midwife team instead.

We took independent advice from a midwife. We found that, although there was evidence that Ms C had received some advice and support regarding breastfeeding, it was not to the standard expected in the board's breastfeeding policy. There was also a lack of entries in the records regarding communication in the immediate post-natal period. From a clinical perspective, there were no concerns about the amount of blood which Ms C had lost, and we found that she was kept under appropriate medical review. On balance, given the failings in record-keeping and communication, we considered that there was a failing in care and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C for the failure to provide her with breastfeeding advice and support in line with the board's policy. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

  • Staff should be aware of the board's breastfeeding policy in order that appropriate advice and support is provided to new mothers.

Updated: December 2, 2018