Overview
The complainants, Mr and Ms C, raised a number of concerns about the midwifery care and treatment provided to Ms C from 15 January 2009, prior to her admission to the Southern General Hospital (the Hospital) on 17 January 2009. Following admission later that day, their baby daughter (Baby C) was stillborn.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the ward based telephone assessment procedure was inadequate (upheld); and
- (b) there was a failure to identify the changing presentation of Ms C prior to admission (upheld).
Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):
- (i) conduct an audit of the telephone triage system introduced in January 2010, to ensure its effectiveness;
- (ii) remind midwifery staff of the need to fully record and document all telephone contacts to ensure continuity of care when more than one telephone contact is made and more than one member of staff has been involved in handling the calls;
- (iii) conduct an audit to ensure appropriate midwifery staffing levels are being maintained;
- (iv) consider amending the Review to take into account the Adviser's comments at paragraph 24; and
- (v) provide a full apology to Mr and Ms C for the failures identified in this report.
The Board have accepted the recommendations and will act on them accordingly.