Decision Report 202110548

Summary

C complained that when they developed complications in their pregnancy, the care that they received fell below a reasonable standard. C was six weeks pregnant and considered a high-risk pregnancy due to four previous caesarean section procedures, as well as surgery to reverse a previous sterilisation. C said that they were treated with a lack of empathy and courtesy by staff during scanning. C also complained that they were refused admission despite being known to be a high-risk pregnancy and despite developing vaginal bleeding. When C was admitted they believed that their surgery was unreasonably delayed, resulting in an avoidable rupture to their fallopian tube.

We took independent advice from both a registered nurse and a consultant obstetrician (the branch of medicine and surgery concerned with childbirth and midwifery). We found a number of failings on the part of the board. However, the board submitted new information, which included sections of C’s medical records which had not been provided previously. The board acknowledged that this was a failing on their part. We reviewed this information and determined that some of the original questions over the actions of the board were answered by this information. We upheld the complaint that the board failed to provide a reasonable standard of care during C's admission. In relation to C's complaint about being unreasonably refused admission, we found that C was treated reasonably and that the board demonstrated that their procedures were followed by staff. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.

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

• A standard operating procedure (SOP) should be developed for the reporting of results in early pregnancy, so that the roles and responsibilities of those working in this area are clearly defined.
• Consideration should be given by the board to identifying appropriate communication training for healthcare workers in the early pregnancy unit.

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.