Decision Report 201806812

Summary

C, a support and advocacy worker, complained on behalf of their client (A) and their partner. A and their partner's child (B) was born at 30 weeks gestation. B was severely disabled and died when they were two years old. B's parents had been told that B had suffered hypoxic ischaemic encephalopathy (HIE, a form of brain injury that occurs when the brain does not receive sufficient oxygen) due to a lack of oxygen in the period prior to their birth. Despite HIE being detailed in B's records as a diagnosis, the board contended that B did not have this condition when responding to B's parents' formal complaint.

B's parents considered there to have been an unreasonable delay to A receiving an emergency section following their urgent referral from Peterhead Hospital to Aberdeen Maternity Hospital. C asked us to investigate whether the level of care that A received from the board fell below a reasonable standard and whether any deficiencies in the standard of care may have contributed to B's health problems.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a senior midwife. We found that A was appropriately given a cardiotacograph (CTG, a way of recording the fetal heartbeat and the uterine contractions during pregnancy) at Peterhead Hospital on the first date complained of, and was appropriately transferred to Aberdeen Maternity Hospital. In relation to the second date complained of, we found that A was again appropriately transferred to Aberdeen Maternity Hospital, although we noted that a CTG was inappropriately stopped at one time, once A had been transferred. However, we also found that transfer to the labour ward took place at an appropriate time and that the decision to move A to theatre and carry out an emergency caesarean section was taken at an appropriate time. The advice we were given did not indicate a connection between the results of tests undertaken at this time and any health problems that B suffered following their birth. We considered that the board's overall management of A had been reasonable and did not uphold the complaint. However, we provided feedback to the board regarding record-keeping.