Staff failed to carry out investigations into Miss A’s bleeding in January 2020
18. Miss A complains staff at the Trust failed to appropriately investigate the cause of her bleeding on 3 and 4 January 2020.
19. Miss A says she experienced bleeding from her vagina in January 2020. She attended the Trust and doctors admitted her to the maternity unit. Miss A says doctors monitored the baby but did not investigate her bleeding at all. She says she was in hospital for two days and despite requesting a scan, staff did not perform any scans to identify why she was bleeding. Miss A says she discharged herself after two days as she could not see any point in being there.
20. Miss A’s hospital notes show she attended the maternity unit on the morning of 3 January. The notes state Miss A reported episodes of ‘show’ five times since the night of 1 January. A ‘show’ refers to the mucus plug that protects the cervix coming lose. This can happen a couple of weeks before labour, up until a couple of hours before the start of labour. A show can have blood in it but is usually clear or pink coloured mucus. The notes indicate Miss A did not experience active bleeding while she was in hospital. The staff recorded her observations until Miss A discharged herself on 4 January 2020. The notes show Miss A already had an appointment booked for 6 January.
21. Miss A saw the midwife at home on 6 January. She says the midwife was so concerned the hospital staff had not scanned her, the midwife arranged for her to see the consultant urgently. Miss A went back to hospital and doctors did a scan on 10 January. She said the consultant told her she needed to deliver the baby at that point, and that the baby had not grown. Miss A queries why she had gone three days (Miss A’s recollection of the dates differs to the records) without a scan to tell her this.
22. The Trust’s response said Miss A attended a growth scan on 6 January and it identified there was concern with the baby’s growth. However, the Trust confirmed to us it did not perform any scans on Miss A on 6 January. Therefore, the Trust’s response is inaccurate. This is not in line with the Ombudsman’s Principles for Good Complaint Handling which says the Trust should ‘create and maintain reliable and usable records as evidence’.
23. Miss A had a scan on 10 January and the doctor saw her the same day. The doctor then booked Miss A for an urgent induction of labour.
24. We asked our adviser what should have happened in this situation. He told us the relevant guidance is the Royal College of Obstetricians and Gynaecologists (RCOG) green top guideline 63, Antepartum Haemorrhage . This says when a woman presents with bleeding during pregnancy, doctors should perform a clinical assessment. This is to establish if urgent intervention is needed to manage any risks to the baby or mother. It says staff should triage the mother including noting the history, other symptoms, assessment of the extent of bleeding, the cardiovascular condition of the mother, and an assessment of baby’s wellbeing.
25. Further, it says all women presenting with bleeding should have their pulse and blood pressure recorded. The guidance says maternal investigations will depend on the amount of bleeding. It says staff should consider an abdominal examination, speculum examination (a device placed inside the vagina to allow an examination of the cervix), and vaginal examination. The guidance says staff should undertake both blood tests and an ultrasound. In particular, it says staff should use an ultrasound to exclude placenta previa as a possible diagnosis. The guidance gives the example of a previous scan having shown a low-lying placenta. This is relevant for Miss A.
26. Our adviser told us bleeding during pregnancy increases the risk of a growth restricted baby. Therefore, it is sensible to do an ultrasound scan to measure the growth of the baby. The RCOG guidance says that, following significant bleeding during pregnancy, staff should perform serial ultrasound scans to assess the baby’s growth. It says staff should reclassify pregnant women as high-risk, at least until serial ultrasound scans demonstrate the baby is growing normally.
27. In Miss A’s case, the notes demonstrate staff recorded Miss A’s blood pressure and pulse. Miss A also underwent a speculum examination, abdominal examination, and vaginal examination. Staff also carried out blood tests. There is evidence in the notes that staff considered her history of possible placenta previa and vasa previa from previous scans.
28. The reviewing doctor only recorded an ultrasound scan on the plan when Miss A wanted to discharge herself on 4 January. This note says, ‘scan for growth and placenta site’. The notes also say the consultant advised Miss A to stay in hospital until 24 hours after the last bleeding episode, but that she preferred to go home. The notes say staff advised Miss A should keep her follow up appointment on 6 January 2020.
29. Our adviser told us this clinical situation indicated Miss A needed an ultrasound scan. There is no specific guidance as to when. They said it would be reasonable to undertake the scan within 48 hours. This is because of the need to see if a problem with the placenta causing the bleeding, and to assess the growth of the baby.
30. We can see the consultant considered an ultrasound on 4 January when Miss A wanted to self-discharge. But we cannot see any consideration was given to performing an ultrasound scan in the 24 hours before. This is not in line with the RCOG guidance. Given Miss A’s reported desire for a scan, on balance it seems reasonable to accept that if the Trust had communicated to her that a scan was necessary, she would not have self-discharged. Therefore, we consider the staff failed to communicate the need for the scan to Miss A, despite the consultant’s plan. We have seen no evidence that staff organised the recommended scan, even though the evidence suggested she should have had one. On this basis, we find there is a failing around the Trust’s investigations into Miss A’s bleeding.
31. Miss A has not said there was a clinical impact from this identified failure. However, Miss A says her entire experience caused her to feel low and experience anxiety around whether she would be able to have children in the future. She questioned why she was left for days without a scan, and then needed an urgent induction of labour.
32. It is reasonable to say Miss A experienced anxiety after the Trust potentially failed to adequately investigate the cause of her bleeding. Her anxiety may well have been compounded by inaccurate information in the Trust’s response to this issue. The Trust’s responses did not acknowledge the impact of this failing on Miss A.
The staff communication about delivery options between 10 and 12 January
33. Miss A complains staff did not give her information about her delivery options, after finding out her baby’s growth was restricted. She said that when she went back into hospital on 10 January, staff told her she would need to deliver the baby ‘now’. She says staff told her to go home and get her belongings then return to hospital. She felt staff were treating it as an emergency. The Trust’s records say Miss A requested to go home and collect her belongings.
34. Miss A had her first medication for induction when she returned to hospital. After 24 hours, there was still no sign of her labour starting. She felt the Trust’s communication around this was bad. She thought she would have to have a caesarean section (C-section) as staff had previously said this during her ultrasound scans earlier in her pregnancy. She felt that she did not know what was happening and why. She recalls waiting another 24 hours to see another doctor. That doctor told her there was no need for C-section. She remembers having other medication for induction and hours later she went into labour.
35. Our adviser explained Miss A’s delivery options in consideration of her presentation. RCOG’s green top guideline 31 on the management of Small-for-gestational-age fetus, says that when the Doppler (measurement of blood flow in the umbilical cord) is abnormal, staff should recommend delivery no later than 37 weeks of gestation. An abnormal reading for the Doppler is significant in small-for-gestational-age babies. This applies to Miss A’s baby.
36. Miss A’s ultrasound scan on 10 January shows the Doppler reading was ‘high’, which is abnormal. In addition, the head circumference (measurement around the head) and biparietal diameter (measurement of the developing skull) are noted as being below the third centile. The growth centiles are the lines on a growth chart that shows the expected pattern of growth of the baby. Anything below the tenth centile is a potential cause of concern, especially if the growth has crossed the growth centiles. Our adviser explained the baby showed a slower heart rate, which may have been due to the placenta no longer working properly in supplying adequate oxygen and nutrients to the baby. Along with the abnormal Doppler, these are indications for delivery by 37 weeks. Therefore, the Trust’s recommendation for delivery is in line with guidance.
37. With regards to the options for delivery, the guidance says in babies with an abnormal umbilical artery Doppler (which was present in this case), staff can offer induction of labour. It highlights there is an increased risk of emergency C-sections and recommends continuous monitoring of baby’s heart rate. Therefore, the Trust appropriately recommended induction of labour as per the guidance. The guidance suggests staff should not recommend a C-section given Miss A’s presentation.
38. Our adviser explained induction of labour is also more likely to lead to a successful vaginal delivery in women who have previously had normal births, which Miss A had.
39. While we can see that the plan was always to induce labour, the notes do not comment on the discussions staff had with Miss A about that process. Therefore, we are unable to say that staff fully explained this process to Miss A.
40. We can see Miss A did query whether she would have a C-section on 11 January. The notes say: ‘explained Drs would make that decision. No other queries. No concerns raised’. Further, the notes state on 12 January, Miss A asked to see the registrar about her baby. This was because clinic staff had informed her that she needed to delivery her baby urgently. The midwife discussed Miss A’s concerns with the registrar and noted the registrar would review Miss A once they were free.
41. On 12 January, the registrar reviewed Miss A. The plan states, ‘if no contractions in 2 hours, commence synto’. ‘Synto’ refers to a medicine called syntocinon which helps induce labour. We cannot see evidence in the notes of a discussion regarding the C-section. However, Miss A recalls the doctor telling her it was not necessary.
42. The Trust’s response to this issue said the doctor apologised if they were not clear in their explanation as to why Miss A needed an urgent scan. This does not address the explanation about inducing Miss A’s labour. Later, the Trust’s letter said, ‘the team apologises that they have let you down by not explaining the process of IOL to you’. IOL refers to induction of labour.
43. Miss A felt the communication during this period of time was not adequate and she was unclear on her delivery options. The notes do not evidence any discussion with Miss A about the induction of labour process and what would happen.
44. GMC’s Good Medical Practice says that doctors must share information with patients that they will need to make decision about their care. This includes the options for treatment, associated risks and uncertainties. Therefore, not explaining the induction of labour process and delivery options to Miss A amounts to a failing.
45. Miss A says her entire experience caused her to feel low and experience anxiety around whether she would be able to have children in the future. She said she was unclear on why she was not having a C-section. We appreciate that this could be anxiety provoking in an already stressful situation.
46. The Trust apologised if staff were not clear in the explanation as to why Miss A needed an urgent scan. The team apologised for letting Miss A down by not explaining the process of induction of labour to her. The Trust has not commented on Miss A’s queries around a C-section.
47. Our Severity of Injustice scale assists us in finding appropriate remedies. Level one, where an apology is usually appropriate, refers to frustration, annoyance, and worry, typically arising from one off incident of service failure. It says this is for when there no other adverse effects or ongoing wider impacts. This level is appropriate for ‘minor’ worry. We consider Miss A would have experienced more than ‘minor worry’ relating to the identified failures. In the context of Miss A’s entire experience, particularly around the Trust’s communication, the Trust’s apology does not go far enough to remedy Miss A’s concerns.
The care staff provided for her retained placenta
48. After Miss A had delivered her baby, her placenta did not deliver naturally as it should. This is called a retained placenta.
49. Miss A complains about the way the doctor removed her placenta. She now believes the doctor did not perform the procedure correctly. Given the circumstances, Miss A does not recall the details of what happened. But her sister was present and described the doctor ‘pulling pieces of the placenta out bit by bit’. Miss A’s sister asked the doctor how they would know if they had got it all. She says the doctor replied, ‘I just know’. Miss A also complained that the doctor left the room during the procedure, while Miss A was ‘wide open with fluid leaking’ from her.
50. Our adviser explained a manual removal of a retained placenta involves a medical professional placing their hand inside the woman’s vagina and uterus and pulling the placenta out. The professional then sweeps around inside the uterus again to see if there is any placenta left. This is because placenta can break up if it is particularly stuck to the lining of the uterus.
51. Our adviser explained there is no guidance that says where (as in, location within the hospital) staff should manually remove a placenta if it has been retained after birth.
However, our adviser explained it is known practice and standard procedure to complete this procedure in an operating theatre for very good clinical reasons. These are: • the woman must be anaesthetised and absolutely numb due to the nature of the procedure. This means that staff top up an existing epidural or give a spinal injection. Sometimes, staff use a general anaesthetic. Anaesthetists are best placed to do this within the operating theatre • the area must be clean and sterile to reduce the risk of infection as a result of the procedure. The operating theatre, by nature, is a suitable environment • there is a risk of significant bleeding during and after the procedure. Medical professionals are best placed to deal with a significant bleed in an operating theatre where the correct equipment and clinical team are on hand.
52. NICE clinical guidelines 190 (2014) highlight the importance of analgesia (numbness to pain) during the procedure. In Miss A’s case, the doctor performed this procedure in the room where Miss A gave birth, with only the epidural that staff had previously administered to Miss A. This would not be normal procedure based on the practices described above. On this basis, we conclude there is a failing.
53. Following her discharge, Miss A describes being in a lot of pain and discomfort. She said she was unable to enjoy time with her newborn son. She visited her doctor’s surgery and discovered there was a large part of her placenta still retained. She had to have two invasive procedures to remove the rest of the retained placenta at a different Trust. She describes this as ‘traumatic’.
54. Our adviser explained it is more likely than not that had staff performed the procedure on 12 January in an operating theatre, the retained placenta would not have been left as it was. This is because it is likely that the theatre facilities and anaesthetic would have allowed the doctor to make sure that the uterus was properly empty at the end of the procedure.
55. On the balance of probabilities, we consider that if the procedure had been performed in the correct conditions, Miss A would have avoided the pain, discomfort, and additional operations she experienced.
56. The Trust’s response to this concern indicates staff ‘normally’ perform this procedure ‘in theatre under a spinal anaesthetic’. The Trust said the doctor does not recall leaving the room but apologised for this if they had. The Trust advised it had reiterated to the doctor the importance of carrying this procedure out in an operating theatre under anaesthetic. The Trust apologised this did not happen in Miss A’s case.
57. However, in relation to the retained pieces following the manual removal, the Trust said the procedure is, ‘prone to some degree of error, regardless of whether it was performed in the theatre or not’. But the letter also states: ‘In your meeting with [the consultant] he was unable to confirm whether any particular problems with pain would make a manual removal more difficult in a room or a theatre or if the chances of having retained placental tissue would you have undergone the procedure in theatre instead of your delivery room’.
58. The Trust apologised the procedure did not take place in an operating theatre. But, so far, we cannot see the Trust acknowledged the impacts of this failing on Miss A. If anything, the Trust’s responses gave Miss A conflicting information.
Communication about Miss A’s baby’s haematoma
59. Miss A also complains that the staff did not tell her about her baby’s haematoma until staff were discharging him on 16 January.
60. The first time the baby’s haematoma is mentioned in the notes is on 13 January during the doctor’s ward round which says, ‘Lt side parietal cephalohematoma’. Cephalohematoma is a bruise on the baby’s head caused by a small pool of blood under the skin. NHS advice on cephalohematoma says the bruise is usually nothing to worry about and should disappear with time.
61. The haematoma was noted again during the ward round on 14 January and further on 16 January. However, there is no evidence the staff discussed or explained the haematoma to Miss A.
62. The notes on 16 January, following the discharge planning meeting say, ‘explained swelling on the head can take months to resolve’.
63. The Trust’s response stated the team apologised ‘profusely’ that staff did not explain the haematoma to Miss A. It said it had taken on board Miss A’s concerns and will ensure other mothers do not have to experience the same.
64. Both GMC and NMC code of practice guidance highlights the importance of explaining conditions, treatment, and associated risks to patients. In Miss A’s case, there is no evidence staff did this with regards to her baby’s haematoma. In addition, the Trust accepted this in its response. Therefore, there is a failing here.
65. Miss A says the experience on the neonatal ward was mentally distressing. She worries about the impact of the haematoma on her son’s development.
66. We appreciate a lack of communication about a bruise on her newborn baby’s head may cause distress and worry. However, we are unable to say that the failing in communication would impact Miss A’s son’s long-term development. Miss A confirmed that the haematoma had gone by the time a consultant conducted a telephone review with her in August 2020. Therefore, we cannot say there is any lasting clinical impact.
67. In the context of Miss A’s entire experience, particularly around the Trust’s communication, the apology does not go far enough to remedy Miss A’s concerns. Miss A would like to achieve service improvements and the Trust has advised it would learn from Miss A’s experience. However, it did not explain how it would do this going forward.