Decision Report 202006731

Summary

C, a support and advocacy worker, complained on behalf of their client (A) who was unhappy with the care and treatment they received during the birth of their child (B) and whilst they were a patient on the postpartum ward.

A's labour progressed very quickly, B's heart rate dropped, and decisions were made to deviate from the birthing plan as a result. A was unhappy with decisions that were made, the care received from midwives, and the lack of communication with them about what was happening. A also had concerns about the postpartum care they received, as they required a blood transfusion and felt their concerns were ignored by staff.

The board considered appropriate guidelines were followed and appropriate action and decisions were made in the circumstances. There was a need to deliver B urgently as there was evidence of distress. In relation to the care A received after the birth of B, the board said they did not consider there were any delays in the care provided to A, or the monitoring of their condition. They did identify an issue with documentation and highlighted that there should always be a handwritten contemporaneous record. This was addressed with staff members involved.

We took independent advice from two clinical advisers: a consultant obstetrician (a specialist in pregnancy and childbirth) and a registered midwife. We found that the care and treatment provided to A during labour was reasonable in the circumstances. We also considered the care and treatment provided by midwives on the postnatal ward was reasonable. We noted that there was a debrief in this case however, given the events of the birth, further debriefing at a senior level may have been helpful. We provided the board with feedback on this point.

We found that the care and treatment provided to A during the birth of their child and postnatally was reasonable and required in the circumstances in which B's health was at significant risk. Therefore, we did not uphold C's complaints.