Overview
The complainants (Mr and Mrs C) lost their son (Baby A) following his premature birth on 5 January 2011. Their complaint concerns the care and treatment provided at Caithness General Hospital, Wick (Hospital 1) and Raigmore Hospital, Inverness (Hospital 2) during and after Mrs C's pregnancy. Mr and Mrs C believe that they received a poor standard of care from both Hospital 1 and Hospital 2 and said that the loss of Baby A has had a devastating effect on their lives.
Specific complaints and conclusions
The complaints which have been investigated are that Highland NHS Board (the Board):
- (a) unreasonably failed to follow Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines when carrying out Mrs C's amniocentesis procedure (upheld);
- (b) inappropriately carried out the amniocentesis procedure in Hospital 1, despite an earlier NHS Quality Improvement Scotland audit report suggesting this should not happen (not upheld);
- (c) unreasonably failed to inform Mr and Mrs C that Baby A had an abdominal wall defect which was detected at the time of the amniocentesis procedure (upheld);
- (d) unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and Mr and Mrs C were not given the opportunity to hold him (upheld);
- (e) inappropriately placed Baby A in what looked like a cardboard box (not upheld); and
- (f) unreasonably failed to arrange a consultant review to determine what went wrong and what implications this could have for a future pregnancy (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that each operator at Hospital 2 is compliant with the RCOG Green Top Guideline No 8 on amniocentesis;
- (ii) review the amniocentesis consent form and patient information sheet used at Hospital 2, so as to take account of the five good practice points referred to in paragraph 17; 20
- (iii) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (a);
- (iv) review the local guidance at Hospital 1 and Hospital 2 concerning suspected fetal abnormalities discovered on any obstetric ultrasound scan. Where an abnormality is suspected there should be a clear pathway for specialised fetal medicine assessment and no delay in referral of the patient to a specialised hospital department;
- (v) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (c);
- (vi) provide evidence of the review of the guidelines for staff referred to in the letter from Doctor 3 to Mr and Mrs C dated 21 April 2011;
- (vii) reflect on the Adviser's comments about examination options after a stillbirth/late miscarriage where the baby has a structural abnormality; and
- (viii) review Hospital 2's post mortem patient information sheet and consent form, so as to include the four examination options listed in paragraph 74.
The Board have accepted the recommendations and will act on them accordingly.