Decision Report 201708139

Summary

Miss C complained about the care and treatment she received from the Princess Royal Maternity Hospital. She raised concerns about the general anaesthetic she was given during her emergency caesarean section, which she said was given the wrong way round and jeopardised her ability to breathe, risking both her and her baby's lives.

We took independent advice from a consultant anaesthetist who covers obstetric (medical specialism for pregnancy and childbirth) theatres as part of their elective and emergency work. We found that the sequence of drug administration in Miss C's case was wrong and could have caused Miss C difficulty breathing, but the awareness of this would have lasted for only a few seconds at most. There was no risk to Miss C's baby from this drug error and the risk to Miss C was limited to the unpleasant experience she suffered, but there would not have been any risk to her life. Given the failing in the administration of the drugs, we upheld this part of Miss C's complaint.

The board acknowledged their failing in this case and took appropriate remedial action on this matter. However, we made one recommendation for further action by the board.

Miss C also complained that she developed a chest infection and contracted Clostridium Difficile (bacteria that can infect the bowel and cause diarrhoea) whilst in hospital. We did not identify any failings by the board in these areas. We did not uphold this part of Miss C's complaint.

Recommendations

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

• Consideration should be given to the supply of pre-filled syringes of suxamethonium, as raised by the board's departmental morbidity and mortality meeting.