Overview
The complainant (Mr C) complained that his wife (Ms A) had not received appropriate care and treatment when they both attended the Obstetric Triage Department, Simpson's Centre for Reproductive Health (the Centre), prior to the birth of their baby daughter (Baby A), and that Baby A suffered severe medical complications as a result.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Centre failed to detect problems with Ms A's pregnancy and failed to carry out appropriate tests when she attended the Centre on 15 and 16 June 2008 (upheld);
- (b) the Centre failed to take Mr C and Ms A's concerns and questions into account on 15 and 16 June 2008 (upheld);
- (c) the Centre failed to give Mr C and Ms A correct advice on 15 and 16 June 2008 or to ensure that adequate follow-up support was in place and offered to Mr C and Ms A on 16 June 2008 (upheld); and
- (d) on 23 June 2008 there was a time lapse of more than 30 minutes (the recommended practice) from the decision to perform an emergency lower uterine caesarean section to the start of this procedure (upheld).
Redress and recommendations
The Ombudsman recommends that Lothian NHS Board (the Board):
- (i) inform him of the measures being undertaken to address the issues raised within paragraphs 26, 27 and 28;
- (ii) inform him of the measures being undertaken to address the inadequate level of staff interface and communication with Mr C and Ms A at the Centre;
- (iii) inform him of the measures they take to ensure that the practice (when presented with a patient with reduced foetal movement) is adhered to, with reference to NICE Antenatal Guidelines 2008;
- (iv) inform him of the measures undertaken to ensure that the delay which occurred in this case, from decision to 'knife to skin', does not recur in a similar situation; and
- (v) issue Mr C and Ms A with a formal written apology for the inadequate standard of care and treatment Mr C and Ms A received on 15, 16 and 23 June 2008, prior to the birth of Baby A, as identified in heads of complaint (a), (b), (c) and (d).
The Board have accepted the recommendations and will act on them accordingly.