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Case ref:201707418
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Date:May 2019
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Miss C complained about the care and treatment she received at the Royal Alexandra Hospital. Miss C complained that staff failed to recognise that her waters had broken, that she was not allowed an epidural (anaesthetic introduced into the space around the spinal cord to produce loss of sensation below the waist) and that she was advised that she was not allowed gas and air as it was not available.
We took independent medical advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a midwife. We found no evidence in the records of Miss C's water breaking. However, we considered that the management of Miss C's analgesia (pain relief) as she awaited transfer to the obstetric unit for epidural was unreasonable as she should have been offered pain relief such as gas and air, further oral analgesia or injections of opiate analgesia. Therefore, we upheld this aspect of Miss C's complaint.
Miss C also complained that her baby (Baby A) was not fed or put in a nappy after delivery, did not go to special care and nobody checked on them when she was still in theatre. We found that appropriate steps were taken by the board to ensure that Baby A was cared for. Due to an emergency situation with Miss C, and as findings of Baby A's examination were normal, we found that it was reasonable for Baby A to be left with a family member. We also found that the delay in transferring Baby A to special care was not unreasonable, given that Miss C's care was the priority post-delivery. Therefore, we did not uphold this aspect of Miss C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Miss C for the failing in the provision of pain relief. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future:
- Appropriate pain relief should be provided to patients awaiting transfer to the obstetric unit for epidural.