Overview
The complainants, Mr C and Ms C, raised a number of concerns about Ms C's unplanned homebirth of their daughter (Baby A), and her death. The complainants believe that the loss of Baby A was totally avoidable and blame Highland NHS Board (the Board) for what happened.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board failed to provide adequate advice, care and treatment before, and during, the birth of Baby A (upheld);
- (b) the Board failed to provide adequate care and treatment to Mr and Ms C following the birth (upheld);
- (c) the Board failed to keep adequate and timely records of the birth and aftercare provided to Ms C (upheld);
- (d) the Serious Untoward Incident report failed to investigate and report adequately on all the issues regarding the birth and aftercare and the Chief Executive's response failed to investigate the matter adequately or to make any recommendations to avoid a recurrence (not upheld); and
- (e) the Board incorrectly stated that Baby A was stillborn (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board: Completion date
- (i) make a full and sincere apology for the failures identified in Complaint (a); and
- (ii) emphasise to all midwifery staff the necessity of compliance with the relevant rules in relation to the completion of notes.
The Board have accepted the recommendations and will act on them accordingly.