Summary
Mr and Mrs C complained about the management of Mrs C's pregnancy, leading up to the stillbirth of their baby. Mrs C experienced increased blood pressure during pregnancy, as well as slightly raised urine protein levels. These can be signs of pre-eclampsia (a condition that can affect pregnant women, particularly during the second half of pregnancy, which can lead to serious complications for both mother and baby).
About 38 weeks into Mrs C's pregnancy, a plan was made for induction in a week's time. In the meantime, Mrs C was admitted overnight for monitoring of her high blood pressure, and she also attended a follow-up appointment where a cardiotocography (CTG) was carried out. The CTG showed some problems of loss of contact and deceleration of heartbeat, but staff thought this was due to Mrs C's movements, and she was discharged. Sadly, when Mrs C returned two days later for the induction, her baby was found to have died (he was stillborn the next day). Mr and Mrs C gave consent for a post-mortem examination, which showed Mrs C's placenta had not been functioning properly, which was consistent with pre-eclampsia.
Following discussion with the consultant in charge, Mr and Mrs C complained to the board. While the board had begun carrying out a routine review of Mrs C's care (which they do for all stillbirths), they also carried out a further clinical review of the care (the REI review) in response to the complaint. This review found that there was no clear diagnosis made between gestational hypertension (high blood pressure) and pre-eclampsia for Mrs C. It found that the local guidance about when to measure urine protein levels (a test for diagnosing pre-eclampsia) differed from the National Institute of Health and Care Excellence (NICE) guidelines about this. The REI review also found there was a lack of continuity of care, and the way that records were kept made it difficult to identify trends in blood pressure recording and blood results in this case.
Following the REI review, the board put in place an action plan for improvement, including amending their guidelines to be consistent with NICE guidelines. However, the results of the REI review were not shared with Mr and Mrs C. While the board intended to share the results, they felt it would be easiest to do this in a meeting. A complaint response had already been drafted before the REI review was finished (indicating that the management of Mrs C's pregnancy was reasonable), and the board simply added a line stating that a review had been carried out and inviting Mr and Mrs C to contact them for a meeting. The rest of the letter was not updated to include the outcomes from the REI review.
After taking independent clinical advice from a midwife and two obstetrics and gynaecology consultants, we upheld Mr and Mrs C's complaint about the management of her pregnancy. We found the board failed to conduct further tests to clarify Mrs C's diagnosis (between high blood pressure and pre-eclampsia), contrary to NICE guidance. We also found the board had failed to recognise abnormalities on two CTG recordings. We did not uphold Mr and Mrs C's complaints about the continuity of care, their involvement in the REI review or the bereavement support made available to them, although we gave the board some feedback on these points.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr and Mrs C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
The Board failed to conduct further tests to clarify Mrs C's diagnosis; and failed to recognise abnormalities on two CTG recordings |
Provide Mr and Mrs C with a written apology that meets the SPSO guidelines on making an apology available at https://www.spso.org.uk/leaflets-and-guidance |
Copy of apology letter
By: 16 August 2017 |
We are asking the Board to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
|
The Board failed to recognise abnormalities on two CTG recordings |
Staff should competent and confident in interpreting CTGs, taking into account the clinical background of the case |
Evidence that the Board has reviewed midwifery and obstetrics staff competence in conducting CTG, delivered appropriate training and development, and has a plan to ensure this is kept up to date By: 11 October 2017 |
|
The Board's complaint investigation did not identify all the failings in Mrs C's care |
Clinical staff involved in Mrs C's care and in the complaint investigation should reflect on and learn from the findings of this report |
Evidence that my findings have been shared, with appropriate support, with staff involved in Mrs C's care and in the REI review By: 16 August 2017 |
|
The Board's complaint response did not include the information and findings from their REI review |
Where a clinical review is undertaken as part of a complaint investigation, the complaint response should include the findings of the review |
Documentary evidence that the Board has processes in place to ensure someone involved in the review writes or reviews any complaint response By: 11 October 2017 |
Evidence of action already taken
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
|
What we found |
What the organisation say they have done |
Evidence SPSO needs to check that this has happened and deadline |
|
The Board found the layout of maternity records could be improved to ensure key information is easily accessible to all clinical staff |
Improve the layout of records, including by:
|
Evidence that the changes in record layout have been implemented By: 11 October 2017 |
Feedback
Complaints handling: It was good practice by the Head of Midwifery/Nursing to escalate this complaint for a multi-disciplinary REI review (due to her concerns about the draft complaint response). However, the results of the REI review were not reflected in the final complaint response, and were never provided to the family (other than an offer to meet and discuss the results, which was not followed up when the family did not get in contact). If the Board had shared the REI review results and made appropriate apologies, this complaint might have been resolved earlier.
Response to SPSO investigation: The Board responded promptly to our enquiries.
Points to note: The professional advisers raised several points for the Board's consideration:
- In relation to continuity of care, Adviser 2 suggested the Board could consider how often women undergoing surveillance for high blood pressure are booked to see their own consultant (for example, in an antenatal clinic), so that decisions could be made with more continuity.
- In relation to the REI review, Adviser 3 suggested the Board may wish to review their guidance on clinical reviews prompted by complaint investigations, to ensure that families who wish to be involved in a review have this opportunity.
- In relation to support following a stillbirth, Adviser 1 said it is good practice for maternity units to have at least one member of staff who has specialist knowledge and training in bereavement care, and recommended that the Board should seriously consider and agree the business proposal for a bereavement midwife.