Decision Report 202201723

Summary

C complained about the care and treatment provided by the board in the lead up to the delivery of their twin babies. One of the twins (A) was stillborn.

C complained that the board failed to provide reasonable care and treatment during C’s pregnancy. We took independent advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that while many aspects of the care and treatment were reasonable, the omission of some key measurements and tests was unreasonable and did not accord with guidelines. This impacted on clinicians being able to reach a fully evidenced position on what care was appropriate. Therefore, we upheld this part of C's complaint.

C complained that the board failed to reasonably communicate the risks and options available to them. We found that the records indicated that the board reasonably communicated with C in relation to the risks and options available to them. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to reasonably investigate C’s concerns. We found that many aspects of the reviews which were carried out were reasonable. However, we found that the reviews failed to identify that the significance of the lack of the measurements being taken was unreasonable, leading to a delay in identifying learning that could be taken forward. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Where adverse event(s) occur the review should be thorough and identify all relevant learning from the event.
• Where it is considered that there are growth issues in relation to a fetus, appropriate investigations and tests, including measuring the pulsatility index as required, should be carried out in line with relevant national guidance.

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.