Overview
The complainants (Mr C and his partner Ms C) were unhappy about the care provided to Ms C during her pregnancy by Lanarkshire NHS Board (the Board). Sadly, Mr and Ms C's daughter (Baby A) was stillborn on 21 October 2007. Mr and Ms C considered a number of warning signs had been missed and, in particular, a scan at 36 weeks which showed the umbilical cord near Baby A's neck should have been followed up. They also complained about the postnatal care provided and that the response to their complaint was not adequate.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the care and treatment provided to Ms C during her pregnancy was inadequate (upheld);
- (b) there were failings to ensure appropriate support was provided following the death of Baby A (upheld); and
- (c) the response to Mr and Ms C's complaint was not adequate (partially upheld, to the extent that full information was not provided at the time of Mr and Ms C's complaint).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) reassess the training provided to midwives on cardiotocographs, given the failure to recognise, record or follow up the deceleration correctly;
- (ii) review the use and purpose of the Board's telephone call records, given the failure to complete any record on 18 October 2007 and the presence on file of a badly completed record;
- (iii) apologise to Mr and Ms C for failing to recognise, record and respond appropriately to the deceleration;
- (iv) review their standard care pathway for bereaved parents, in light of the concerns raised in this report and the best practice examples elsewhere in NHS Scotland, and ensure that parents are given timely advice about counselling;
- (v) review the supervision arrangements for their ante-natal clinics taking into account the advice received in paragraph 17 and inform the Ombudsman of action taken as a result of this review;
- (vi) apologise to Mr and Ms C for failing to communicate with their GP, in line with their procedures, and for the time taken to provide them with information about counselling; and (vii) when responding to complaints, take into account the need to provide as full information as possible, particularly where interviews have been held with staff.