Decision Report 201805588

Summary

Mrs C complained about the care and treatment she received during childbirth from the board. Mrs C's baby was born by low cavity forceps delivery which required her to have her legs in supports. She found the process painful and traumatic and complained that staff failed to explore or act upon her pain. She also said that the orthopaedic (specialists in the musculoskeletal system) care she received after the birth was unreasonable and that she was not satisfied with the way the board investigated her complaint. The board said that as a result of her complaint they had learned not to make assumptions when a woman was very vocal during labour but that she had had anaesthetic to deal with pain. They also apologised for the lack of support she had received and for poor communication.

We took independent advice from a midwife and consultants in orthopaedics, and obstetrics (the medical specialism for pregnancy and childbirth) and gynaecology (medicine of the female genital tract and its disorders). We found that it had been reasonable to undertake a forceps delivery as Mrs C had been pushing for an hour without her baby being delivered. To assist this, Mrs C's legs had been placed in lithotomy (leg restraints). This was associated with symphysis pubic diastasis (the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture) in up to 25% of cases and Mrs C suffered this. While Mrs C said that she was crying out in pain as a consequence, the clinical records did not support this, therefore, we could not conclude that she was ignored. However, we noted that there was no mention of a pudendal block (local anaesthesia commonly used to relieve pain during the delivery of a baby by forceps) in Mrs C's records. On this basis, we considered that the board failed to explore or act upon the causes of Mrs C's pain and upheld this aspect of her complaint.

We found that Mrs C's orthopaedic care and management after the birth had been reasonable and did not uphold this aspect of her complaint. However, the board did not investigate Mrs C's complaint well and she experienced several months delay before receiving the boards response. This was too long and, accordingly, we upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in responding to her complaint and for the lack of detail in her clinical records, in particular that there was no mention of a pudendal block. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All relevant documentation should be completed appropriately and as required. In line with Nursing and Midwifery Council/General Medical Council guidelines.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the board's formal complaints procedure.

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.