Failure to provide adequate and timely pain relief
29. We understand that Dr I feels that Mrs I was not provided with adequate or timely pain relief whilst she was a patient at the Trust.
30. Mrs I’s medical records show that she first complained of pain on 27 September and the Trust therefore prescribed her pain relief. Mrs I then complained of increasing pain shortly after midnight on 28 September. The Trust prescribed a low dose of morphine, and again at 6.30am. Mrs I’s medical records detail that she received 1g of paracetamol four times a day until she was discharged. The Trust also prescribed her with dihydrocodeine, which is an opiate painkiller, at 30mg twice a day until discharge. The Trust also gave her a low dose (400mg) of ibuprofen.
31. In its response, the Trust said, ‘the team were following an appropriate pain ladder which incorporates non-opioids, adjuvant and short acting oral opioids for acute pain’.
32. We have carefully considered the relevant clinical records and the RCEM guidance, which says that for moderate pain (which is score between four and six out of a maximum of ten) staff should prescribe a patient with an oral non-steroid anti-inflammatory drug (NSAID) and codeine.
33. The RCEM guidance goes on to say that the standard paracetamol dose is 1gram qds (four times a day), the standard ibuprofen dose is 400mg, the typical codeine dose is between 30 and 60mg, and for morphine the dose is between 0.1 and 02mg/kg.
34. We therefore consider that as Mrs I was recorded as suffering from moderate pain, the Trust correctly prescribed her ibuprofen at 400mg and dihydrocodeine at 30mg. We also consider that when her pain increased the Trust appropriately prescribed the correct dose of morphine. We understand from the evidence available to us that the pain relief was appropriate to prevent pain and stop any breakthrough pain from occurring, in line with the RCEM guidance.
35. We can see from Mrs I’s medical records that paracetamol and dihydrocodeine were given throughout her stay and were assessed to be enough to effectively manage any discomfort. This is because after each dose the Trust recorded her pain score to be zero. The Trust then prescribed Mrs I with morphine twice when she complained of further pain. Her records show this lowered her pain score and was therefore effective.
36. Based on the evidence we have seen, we consider that as Mrs I was suffering from moderate pain, the Trust prescribed correct pain relief. We have also seen evidence staff gave her stronger pain relief when her pain increased. We also consider that the pain relief was likely effective, as Mrs I’s pain scores reduced after she was prescribed with her pain medication. We have therefore not seen evidence of any failings in the management of Mrs I’s pain.
Failure to follow-up on clinical results and lack of a system to do so
37. Mrs I had a urine test on 25 September 2018. Dr I is unhappy that the Trust did not follow this up until several days had passed. Dr I is concerned staff only looked at the results and followed this up following his wife’s request.
38. The Trust said the laboratory received the urine test at 6am on 25 September. The results were available in approximately 49 hours, at 7am on 27 September. However, the results were not reviewed by the midwife until 12.30am on 28 September.
39. There is no specific guidance on how quickly the Trust should have reviewed the test results and acted on the results. However, GMC Good Medical Practice general guidance, section 15b says clinical staff should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’. We do not consider the gap of 17.5 hours between test results becoming available and the midwife review to be representative of prompt action.
40. The Trust does not have any policy in place with regards to how quickly test results should be reviewed. However, in its response dated 19 September 2019 it said, ‘the follow up of the results had been a matter of concern at the time and the results should have been reviewed earlier.’
41. Therefore, based on the evidence we have seen so far, we consider this to be an indication of a failing. This is because we consider a 17.5 hour wait before reviewing the results is excessive and not in line with the GMC guidance referenced above.
42. We have therefore considered the likely impact of this mistake. We are aware that if UTIs go untreated they can become very severe and in some cases lead to sepsis. Sepsis is when the body overreacts to an infection and causes significant harm to the organs and other tissues, and it can be fatal. However, in Mrs I’s case the UTI did not go on to develop into a severe infection or become dangerous.
43. We do consider that the earlier administration of antibiotics may have decreased the pain that she was experiencing. However, as set out in the previous section, we do not consider that Mrs I experienced any avoidable pain as we can see that that her pain was adequately managed. The Trust administered pain relief whenever Mrs I was in pain, and this appeared to be effective as her pain score decreased after the administration. We therefore consider that there has been no clinical impact on Mrs I due to the Trust not reviewing her urine test results earlier.
44. However, we consider this led to a negative experience and additional stress for both Dr and Mrs I. They were aware while Mrs I was in hospital and had only recently given birth that she had not yet received her test results, and they were obviously keen to be reassured that all was well.
45. We have considered what the Trust has done to put right the distress the delay caused. The UCLH complaints policy says that, ‘We may not be able to change your experience, but we do want to learn from it’. Our Principles for Remedy also say that if an organisation makes mistakes, they should either put people back in the position they were in before the error or compensate them appropriately. This is often by way of recognition that the organisation has made a mistake and by providing an apology, although it depends on the seriousness of the impact the mistake has caused.
46. The Trust has acknowledged a failing in the time taken to review Mrs I’s urine test result, and it has apologised for this and any emotional impact this had on Dr and Mrs I. The Trust has also explained that test results are now available electronically so are visible to all staff as soon as they are released. It also said that this new system helps to identify any abnormal or positive results, so it is easier for staff to act on any results that are priority.
47. Based on what we have seen, we do not think we need to take further action here. Having considered the Trust’s complaint policy and our own Principles for Remedy, we are satisfied that the Trust has appropriately recognised its error and apologised for the distress it caused. In our view, this is a proportionate remedy for the emotional impact of the delay.
Midwives did not seek professional input when required
48. We understand that Dr I is concerned that the midwives in charge of Mrs I’s care did not seek medical input at appropriate times.
49. We can see from Mrs I’s clinical records that at 9pm on 27 September, she complained of unusual abdominal pain on her right-hand side. Following this, the midwife in charge of her care at the time carried out a physical examination and prescribed analgesia. The records show that the midwife checked for bleeding and checked that her uterus was not contracting.
50. The NICE guidance says that if a new mother is complaining of abdominal pain it is likely to be an infection. However, blood loss could be associated with a postpartum haemorrhage, i.e. a rip or tear to a blood vessel causing bleeding. As such, it was in line with the guidance for the midwife to have carried out this check.
51. Mrs I then complained of further pain at 12.30am on 28 September. The Trust provided Mrs I with further analgesia and it was at this point that the midwives noted her urine test results. The clinical records show that Mrs I had trouble walking, so the midwife felt her uterus and noted the frequency of her passing urine. Mrs I’s urine sample showed the bacteria Enterococcus faecalis (E-coli). Therefore, the midwife called for a doctor to assess Mrs I. However, as they were not able to attend her symptoms and test results were discussed over the phone, where the doctor decided the treatment plan should be to provide antibiotics.
52. The NMC guidance says that a midwife should ‘make a timely referral to another practitioner when any action, care or treatment is required’. We can see that the midwife requested the input from a doctor at the appropriate time and in line with the NMC guidance. This is because Mrs I was complaining of increasing pain and she had a positive urine test result for E-Coli. We therefore consider that as further treatment was likely required, it was appropriate and in keeping with the guidance for the midwife to contact the doctor at this point. As the doctor was unable to attend to assess Mrs I at that time, the midwife had an appropriate telephone conversation to discuss symptoms and the test results.
53. We therefore consider that the Trust midwifery staff acted appropriately and sought input where required. We can see that the Trust midwife appropriately assessed Mrs I when she complained of pain, in line with the relevant guidance, and when it appeared that the pain could be due to an infection a doctor was called for medical input.
Medication prescribed without an appropriate assessment
54. We understand that Dr I is unhappy that the Trust prescribed his wife with antibiotics and analgesia even though a doctor had not seen her or carried out a thorough assessment.
55. Mrs I’s medical records show that at 12.30am on 28 September a midwife asked for a doctor to review her. However, a doctor was not available and so her symptoms and urine test results were discussed over the telephone. It was at this point that the doctor prescribed the antibiotic Nitrofurantoin, commonly used in the treatment of UTIs.
56. The GMC guidance says that, ‘In providing clinical care you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.’
57. As stated previously, we consider that the midwife had an appropriate discussion with the doctor over the telephone regarding Mrs I’s symptoms and urine test results. We therefore consider that the doctor acted in line with the GMC guidance and acted appropriately by prescribing antibiotics based on the information they had received from the midwife, which enabled them to make a diagnosis of a UTI and for treatment to begin.
58. We then looked at Dr I’s concerns that the Trust prescribed analgesia without a full medical assessment. We have previously mentioned in this report that the Trust appropriately prescribed analgesia, in line with RCEM guidance. It was documented in Mrs I’s medical records that the pain relief worked, as after prescription her pain score reduced. We therefore do not consider there to be any failing with the prescription of analgesia, as it was clearly effective and met Mrs I’s documented needs at that time.
The antibiotic Nitrofurantoin was inappropriately prescribed and unavailable, and it took over 6 hours for an alternative to become available
59. As set out above, we understand that Mrs I was diagnosed with a UTI in the early hours of 28 September and the Trust subsequently prescribed her with Nitrofurantoin. However, this antibiotic was unavailable, and it took 6 hours for another antibiotic to be provided.
60. As set out in the previous section, at 12.30am on 28 September a doctor prescribed Nitrofurantoin. However, this antibiotic could not be obtained. The midwife contacted the doctor again at 12.50am and a different prescription was made for antibiotics. However, despite chasing for the new antibiotic at 1.45am and 5am it was approximately 6 hours in total before the antibiotics were given to Mrs I.
61. The Trust has acknowledged the delay and said, ‘The prescription was made based on the sensitivity of the culture. I apologise that we do not stock this as a routine drug and there was a 5 hour and 50-minute delay’.
62. There is no guidance on how regularly the midwife should have attempted to contact the doctor once she had found that the second antibiotic was not available. However, we can see that the midwife appropriately attempted to chase up the prescription at regular intervals, which is in line with the NMC The Code, section 8 ‘Working cooperatively’, which explains nursing and midwifery staff should work with other clinical colleagues for patient safety.
63. We can see that the initial antibiotic prescription of Nitrofurantoin should not be prescribed to women who are breastfeeding, in accordance with the NHS guidance, and this should have been checked before it was prescribed. We therefore consider that the Trust should not have prescribed Nitrofurantoin, given that Mrs I was breastfeeding. However, as the error was recognised only 20 minutes later, was not actually administered and the prescription was changed, we cannot see there was any clinical impact from this error.
64. As we consider this to be a failing, we have considered the impact that this had on Mrs I and her care and treatment. As the prescribing error was identified and put right very quickly after it was made, it did not contribute to any significant delay in Mrs I receiving the second antibiotic. There clearly was a delay in that antibiotic being provided, but not due to the initial error in prescribing Nitrofurantoin. As stated previously, we have seen no evidence that Mrs I’s UTI became more serious due to the delay in providing the second antibiotic, and the records indicate that any pain she was experiencing was being managed appropriately. We therefore consider that there has been no impact on Mrs I’s care and treatment.
A fifteen-hour wait to see a doctor
65. We understand that Dr I is unhappy with how long it took for Mrs I to be seen by a doctor on 28 September 2018.
66. Mrs I’s medical records show the midwife requested a doctor examine her in the early hours of 28 September. However, the doctor did not examine her until 3.15pm that day.
67. The Trust said that given the activity on the maternity ward at the time, Mrs I was not a clinical priority and the midwife in charge of Mrs I’s care at the time took appropriate action. They discussed her symptoms and results of the urine test with the doctor over the phone. On this basis, it explained the treatment it provided was entirely appropriate.
68. As set out previously, a midwife discussed Mrs I’s clinical condition with a doctor over the telephone in the early hours of 28 September 2018, and we have identified no failings on that matter. We can see from Mrs I’s medical records that when she was reviewed by a doctor at 3.15pm on 28 September, she was assessed, further blood tests were requested and a UTI was diagnosed.
69. There is no specific guidance to say how quickly Mrs I should have been seen. The GMC Good Medical Practice guidance section 15 tells us that medical staff should assess and examine patients ‘where necessary’, and in Mrs I’s case there was nothing to suggest that she needed medical review urgently. She was also being monitored by nursing staff during the period where she was waiting for medical review, so if anything had changed her case could have been escalated appropriately at that time.
70. We therefore consider that even though Mrs I had to wait to be seen by a doctor, this was due to a reasonable explanation, i.e. the number of patients needing medical attention at that time, and she was given appropriate oversight in the meantime.
No additional tests carried out by midwives
71. We understand that Dr I feels that the Trust should have carried out further tests such as a high vaginal swab (where samples of any discharge are taken from the top of the vagina) and repeat urine test.
72. The NMC guidance says that a midwife should work within the limits of their competence. As such, we understand that midwives should not arrange for additional tests to be carried out without the direction of a doctor.
73. We understand from Mrs I’s medical records that a doctor assessed her at 3.15pm on 28 September. During this assessment the doctor requested further additional blood tests, but not a high vaginal swab. As the doctor did not request this, the midwives did not carry this task out.
74. With regards to a repeat urine test being carried out, bacteria were present during the first urine sample test. As the bacteria were identified at that time, we have not seen anything to suggest it was necessary to carry out a second test.
75. We therefore do not consider that there have been any failings in this element of the complaint. The midwives appropriately carried out the additional tests that were requested by the doctor, and we do not see they had any authority in their role to carry out any tests in addition to this.
Inadequate number of staff on the maternity ward
76. We understand that Dr I feels that there was not enough staff working on the maternity ward whilst his wife was a patient there. He says that this impacted on her care and treatment.
77. The Trust has said that the ward was appropriately staffed during Mrs I’s admission. The Trust explained its staffing levels have been externally reviewed using an NHS England accredited tool, Birth rate PLUS 2018. This found there was an appropriate, safe number of midwives and support workers covering the postnatal ward at the time of Mrs I’s admission.
78. We understand that Birth rate PLUS is a well-recognised and NICE/RCM accredited tool used throughout maternity units in the UK. It is used to assess safe staffing levels based on the needs of women for midwifery care throughout pregnancy, labour and the postnatal period in both hospital and community settings.
79. The Trust’s response also added it has a mechanism to review staffing levels daily to assess if there is adequate staffing throughout the maternity unit. It also assesses the need for extra bank/agency staff. We understand that this is standard practice in all maternity services.
80. We have therefore not seen any evidence of failings in terms of staffing levels during Mrs I’s admission.
Incorrect information within medical records
81. We understand that Dr I is unhappy that in his wife’s medical records it says that she was suffering from urinary symptoms prior to her diagnosis at 3.15pm by medical staff when she was not displaying any such symptoms. He is concerned staff treated her for a UTI before receiving a clear diagnosis and without her having symptoms.
82. Mrs I’s medical records show that she was suffering from abdominal pain on her right-hand side and was struggling to walk. It also shows that the midwife checked her uterus and that her urine test results showed a bacterium which needed to be discussed with a doctor.
83. The GMC guidance on record keeping says that, ‘you must keep clear, accurate, and legible records which report the relevant clinical findings, the decisions made, the information given to patients, any drugs or other treatment prescribed and who is making the record and when.’
84. We have seen no information in Mrs I’s medical records that said she was suffering from urinary symptoms prior to her diagnosis at 3.15pm. As stated above, irrespective of whether she was showing physical symptoms of a UTI, the urine test results which the midwife reviewed at 12.30am showed evidence of a urine infection, and so we consider that the Trust did the appropriate thing by discussing Mrs I’s conditions and urine sample test results with the doctor over the phone. This is what is documented in the clinical records that we have seen. We can see that following a physical examination by a doctor at 3.15pm, the diagnosis was confirmed. We therefore do not consider that there has been any failing in this element of the complaint and the Trust has acted in line with the GMC standard on record keeping.
Discharge planning was unsafe and not in line with the Trust’s guidance
85. We understand Dr I is unhappy that his wife was discharged at 9:30pm on 28 September. He says that she had not slept and was not ready for discharge. He says that this is supported by the fact that his wife was re-admitted shortly after her discharge.
86. Mrs I was discharged at approximately 9pm on 28 September. Her medical records show that on that day she was prescribed 10mg morphine at 6.20am, 2 doses of paracetamol at 10.52am and 5.17pm, 2 doses of dihydrocodeine at 10.52am and 5.17pm, and 400mg of ibuprofen.
87. The Trust said the practice for the maternity unit is to allow discharge 24 hours a day and 7 days a week, based on patient choice and an assessment that the patient is safe to be discharged. The Trust noted Dr and Mrs I were asking to be discharged. It said a doctor assessed her and then confirmed that she was safe for discharge.
88. The NICE guidance says that every woman should have her discharge planned to go home at a time that is suitable for her and her family.
89. We understand that paracetamol and ibuprofen have no adverse impact on mental awareness, although dihydrocodeine may cause drowsiness. However, Mrs I was given a low dose of 10mg and there was no mention of side effects when this medication was started on 27 September.
90. With regards to morphine, this can also cause drowsiness. However, we understand that morphine is eliminated from the body after 10 to 12 hours. Therefore, as Mrs I’s discharge took place 15 hours after last being given morphine, there is nothing to indicate her discharge was unsafe in this regard.
91. Mrs I’s records show she was keen to be discharged. When Mrs I first arrived on the post-natal ward staff noted her desire to be discharged as soon as possible. The Trust also noted at 8.15pm on 28 September that Mrs I was anxious to return home and therefore it arranged for discharge shortly afterwards.
92. We can see from the clinical records that at the time of discharge Mrs I was clinically well, her UTI was being treated, her observations were normal, she was keen to be discharged and there was no further inpatient treatment required.
93. Due to the pain Mrs I was in, the midwife referred her discharge to a doctor, to make sure her discharge was appropriate and safe. This is also in line with the UCLH discharge policy, section ‘Discharge home,’ which says that a doctor will review the new mother before discharge if clinically needed.
94. We consider that Mrs I’s discharge was in line with guidance, as the evidence indicates she was medically fit and wanted to return home. We do understand the Trust’s website does not clarify discharges could be at any point in the day, including in the evening. The Trust has said it has an open discharge policy in terms of the ‘24/7 functioning’ within an acute maternity ward. It recognised that it could improve its service by clarifying this on its website and it explained it will update its website accordingly to reflect this.
95. We therefore consider that whilst Mrs I’s discharge was safe and in line with applicable Trust policy and guidance. We appreciate that this would have caused some distress and upset for both Dr and Mrs I who may not have been expecting a discharge in the evening.
The complaint process was not open and honest and appeared to favour protecting the department over seeking opportunity for improvement
96. The Trust investigated Dr I’s concerns and issued its response letter on 4 February 2019. As Dr I was unhappy with the response and investigation, he contacted the Trust again. The Trust arranged a meeting on 24 July 2019 and issued its second and final response on 19 September 2019.
97. We have considered these responses. We can see that the Trust confirmed the complaint it was looking into, detailed its findings and identified areas of concern. From this the Trust set out service improvements to ensure that learning is taken from its findings. We can also see that the Trust asked for input from the staff involved in Mrs I’s care and input from other members of staff where helpful in reaching a view.
98. The Trust’s complaint policy says, ‘We will ask the most relevant department to investigate the issues raised and respond to you.’
99. Our Principles of Good Complaint Handling expect organisations to be open and accountable when investigating a complaint. They say organisations should, ‘Be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions. When things have gone wrong, public bodies should explain fully and say what they will do to put matters right as quickly as possible.’
100. Having reviewed the clinical records and the complaint file, we have been unable to find any evidence that the Trust has not been truthful or honest about the care and treatment it provided. We consider that the Trust has investigated the complaint fairly by considering Mrs I’s medical records, talking to the staff in charge of her care at the time and also asking for the clinical input from other members of staff. The explanations set out in its response letters appear supported by the clinical evidence available to us. We therefore consider that the Trust has acted in line with guidance and responded appropriately to the complaint.
The original investigation found no failings, but this was found to be incorrect after a further investigation
101. We understand that Dr I is unhappy as the Trust’s original response letter did not find any failings in the care that his wife was provided. However, upon a request for a further investigation, some errors were identified. He therefore feels that the Trust did not complete a thorough investigation first time round.
102. We can see that in the Trust’s final response, dated 19 September 2019, it acknowledged there were some inaccuracies within its first response. The Trust went on to say that there were errors with the reported timings and that some aspects of Dr I’s complaint needed further investigation. The Trust apologised for any upset or distress caused by its first response.
103. We have considered the Trust’s responses and can see that its original investigation was carried out with reference to the appropriate clinical evidence and complaint correspondence, and it provided explanations which are supported by the records. Although the Trust identified some minor errors and explored additional points which were raised by Dr and Mrs I about the impact and their personal experience after the first response was issued, we do not consider the original investigation to be flawed because of this or that the findings after the second report changed in any significant respect.
104. The Trust’s website states, ‘If you are not satisfied with our response to your complaint you can ask us to: • clarify points or give you further information • consider a meeting to discuss your concerns. You can bring a relative, friend or representative with you • look at your complaint again.’
105. We consider that the Trust appropriately investigated Dr I’s concerns further, following the first response. This is what we expect an organisation to do with regard to listening to service users and revisiting matters where they may have got things wrong. We consider that sometimes an organisation can get things wrong, but it is important that it acknowledges this, puts things right and learn from the events. We therefore consider that as the Trust recognised where some minor errors occurred, listened to Dr and Mrs I’s further concerns and provided a further response there are no failings in the way it handled the complaint.
106. This concludes our report.