23. When looking at whether there have been failings in the service provided, we consider what should have happened. We look at what did happen, and if this was different. If it was, we consider if it fell so far short of what should have happened to amount to a failing. If there was a failing, we look at what impact this had. If it caused a negative impact to the individual concerned, and the organisation has not done enough to put that right, we can make recommendations for it to take further action.
Conversation with EPU on 3 July 2019
24. The guidance explains that women with pain and/or bleeding should first be assessed by a healthcare professional (such as a GP, A&E doctor, midwife, or nurse) before a referral to an Early Assessment Service (EAS). Following assessment, the healthcare professional may refer a woman to an EAS for further investigation which may include an ultrasound scan. The EAS should employ a system which ensures it sees woman referred to its service within 24 hours. The guidance adds, following referral the EAS should offer woman an ultrasound scan to identify indications baby is forming and has a heartbeat.
25. Ms U telephoned the EPU on 3 July 2019. There is no recording of the call available. For this reason, we have considered what Ms U and the Trust’s records say to establish what happened during the call.
26. Ms U says she reported to the HSW she was spotting and in pain. She expected she was miscarrying and requested an ultrasound scan. Ms U says the HSW declined her scan request because the EPU was too busy to see her. She says, because of this, she procured an ultrasound scan in the private sector which cost her £70.
27. The HSW recorded Ms U was very anxious and wanted to speak with the midwife who was unavailable. The HSW advised Ms U to take analgesia for her discomfort and see her GP with her concerns. The HSW also advised Ms U to monitor her vaginal blood loss and call back if the bleeding continued beyond seven days. The HSW said to Ms U that she should attend the EPU if she soaked a sanitary towel within 30 minutes, or if her pain was not controlled with analgesia.
28. Having looked into what happened during the call on 3 July 2019, the EPU Lead at the Trust explained it normally aims to see patients with similar symptoms as Ms U at its EPU. It said on this occasion the EPU had no availability to see Ms U. The EPU Lead concluded ‘I absolutely accept the HSW should have explained this to Ms U in a much more sympathetic manner considering her previous history.’
29. On 3 July 2019, Ms U suspected she was miscarrying. We appreciate Ms U’s pain and bleeding was distressing for her. She called the EPU expecting it would offer to scan her and provide advice on how best to deal with her symptoms and anxiety.
30. We see on 3 July 2019, the HSW explained to Ms U how she could manage her pain and monitor her bleeding. Because the EPU had no availability to scan Ms U, the HSW advised her to see her GP and attend the EPU should her symptoms worsen.
31. We carefully considered what the guidance tells us should have happened during the conversation. While the Trust explained the EPU would normally see women with similar symptoms without a health professional referral, it is under no obligation to do so. The Guidance explains, Ms U should first see a healthcare professional for assessment and potential referral to an EAS. Had she seen her GP on 3 July 2019, they would likely have assessed Ms U and, if clinically indicated, they could have referred her for a scan at the EPU within 24 hours.
32. We see the HSW provided Ms U with a pathway which likely would have achieved the scan she sought, albeit on the following day. We appreciate this meant Ms U would have continued to have pain and bleed and would have to wait longer to establish if she was miscarrying or not. This was likely the cause of Ms U’s anxiety. Other than management advice, the HSW could do nothing more to help Ms U with her anxiety.
33. Having considered what the Guidance tells us should have happened, we find the HSW’s advice to Ms U on pain management and advice to see her GP was in line with its standards. For this reason, we do not uphold this part of the complaint.
34. Ms U says, during the call, the HSW lacked compassion.
35. The guidance requires clinicians to treat all women with early pregnancy complications with dignity and respect. Clinicians should be aware women will react to complications or the loss of a pregnancy in different ways. It should provide all women with information and support in a sensitive manner, considering their individual circumstances and emotional response.
36. Having considered Ms U’s complaint, the EPU Lead found the HSW failed to deal with her with the degree of sympathy the Trust expects of its staff. With this in mind, we consider the Trust breached its own standards and standards under the guidance on sharing information sensitively.
37. Ms U says this worsened her mental health problems.
38. The injustice Ms U claims links closely to the next part of her complaint. For this reason, we will consider the injustice once we consider her complaint about her second telephone conversation with the EPU on 8 July 2019.
Second conversation with EPU on 8 July 2019
39. The Miscarriage Summary directs the Trust to ensure it cancels arrangements for routine antenatal care. It also directs the Trust to discuss questions patients have about their miscarriage, assess psychological wellbeing, and offer counselling if appropriate.
40. The Miscarriage Summary explains the Trust should be aware that grief, anxiety, and depression are common following miscarriage. It recognises the grief following miscarriage is comparable in nature, intensity, and duration to grief in people suffering major loss.
41. Ms U called the EPU on 8 July 2019. On this occasion, she reported to the HSW she had miscarried, and she wished to cancel a repeat scan it had scheduled for her on 11 July 2019. Ms U says, during the call, the HSW failed to show compassion, focussed solely on cancelling the scan appointment, and offered no advice or follow-up care.
42. Having considered Ms U’s complaint, the Trust agreed the HSW focused solely on cancelling the scan appointment. It explained, the HSW should have prioritised Ms U’s wellbeing and how she was coping emotionally and physically following her miscarriage.
43. On 8 July 2019, once Ms U notified the Trust she had miscarried, in line with the Miscarriage Summary, the Trust should have arranged to assess Ms U physically and psychologically and then offered her counselling if appropriate. This did not happen. For this reason, the Trust failed to meet the standard required of it under the Miscarriage Summary. We will consider the injustice which stemmed from this part of the complaint later in our report.
44. Regarding the HSW’s conduct during telephone calls, the guidance explains healthcare professionals should be aware early pregnancy complications can cause significant distress for some women. For this reason, the guidance recognises organisations should treat women with pregnancy complications, and/or loss, in a sensitive manner.
45. We previously explained that the Trust agrees it failed to deal with Ms U with the required degree of sympathy on 3 July 2019. The EPU Lead also found, on 8 July 2019, Ms U did not receive the kind and caring reception it expects from the EPU team. For this reason, we consider the Trust failed to meet the standards required of it for sharing information sensitively during telephone calls with Ms U on 3 July 2019 and on 8 July 2019.
46. Ms U says the Trust’s failure to treat her with compassion and sensitivity added to her distress and worsened her mental health.
47. The guidance recognises early pregnancy complications can cause significant distress. We consider Ms U’s pain, bleeding and miscarriage caused her distress and mental health issues. We believe the Trust’s failure to discuss problems sensitively with Ms U worsened her distress for short periods during each telephone call. As we explained above, on 8 July 2019, the Trust missed an opportunity to arrange support for Ms U’s mental wellbeing.
48. In its initial complaint response to Ms U on 13 August 2019, the Trust explained that the HSW was new to the team and was familiarising themselves with the role at the time of their conversations with Ms U. We see, in the Trust’s response, the HSW apologised to Ms U and assured her they would learn from the experience.
49. The guidance adds, staff working in settings where early pregnancy care is provided should also be given training on how to communicate sensitively with women who experience early pregnancy complications.
50. We appreciate the HSW was new to the role. This may suggest systemic reasons for its failings, either in the Trust’s training and/or monitoring of new staff.
51. We see the HSW apologised to Ms U. We consider this apology alone does not go far enough to put right the added distress they caused Ms U. For these reasons, we uphold Ms U’s complaints about compassion/sensitivity during telephone calls with the HSW on 3 July 2019 and on 8 July 2019. We will discuss recommendations later in our report.
Follow-up care complaint handling
52. The Complaints Policy sets standards a complainant can expect to receive when complaining to the Trust. In line with the Complaints Guidance, we expect the Trust to have properly looked into Ms U’s complaint. It should have kept her updated on its progress and informed her of the outcome. Should it find it did something wrong, the Complaints Policy says the Trust should take appropriate action to put this right.
53. The Ombudsman’s Principles outline the approach we believe organisations should take when delivering good administration and customer service and how to respond when things go wrong. The Ombudsman’s Principles of Good Complaint Handling (The Ombudsman’s Principles) explains, where an organisation has failed, and this led to injustice it should take steps to put things right.
54. Ms U complained to the Trust on 17 July 2019. She says that having notified the Trust of her miscarriage on 8 July 2019, it did not arrange to assess her physical or mental wellbeing. Having looked into Ms U’s complaint on 24 July 2019, the EPU Lead explained to the PALS Lead that the HSW focused solely on cancelling her scan appointment when they should have prioritised her wellbeing and how she was coping emotionally and physically following her miscarriage. On 13 August 2019, the PALS Lead relayed this to Ms U in the complaint response.
55. On 15 August 2019, Ms U complained to the Trust again. She explained to the Trust, following her first miscarriage in January 2019, she underwent blood and pregnancy tests which checked whether her miscarriage had impacted her ability to conceive in the future. She complained that on this occasion, the Trust failed to provide her with the similar blood and pregnancy tests which may have informed her if there was an impact on her ability to conceive in the future.
56. On 16 August 2019, the PALS Lead asked the EPU Lead to consider Ms U’s comments. The EPU explained to the PALS Lead it accepts it did not provide general information and care to Ms U following her miscarriage.
57. Also on 16 August 2019, Ms U received a letter from the Trust inviting her to scheduled antenatal appointments. Ms U’s records show she called the EPU on 23 August 2019. Ms U was very upset and angry that she had been chased for a whooping cough vaccination, ultrasound scan, and Down’s syndrome screening tests. It is noted the Trust said it would make sure future pregnancy appointments were cancelled.
58. The Miscarriage Summary directs the Trust to ensure it cancels arrangements for routine antenatal care. It appreciates miscarriage is a major loss for woman, and grief is at its worst for up to six weeks. With this in mind, we expect the Trust to have acted quickly to cancel antenatal appointments for Ms U. The Miscarriage Summary also directs the Trust to discuss miscarriage with Ms U, assess her physical and psychological wellbeing, and offer counselling if appropriate.
59. The Ombudsman’s Principles say staff should put right what went wrong promptly.
60. As we explained above, the EPU Lead considered Ms U’s complaint on 24 July 2019, it found the HSW only cancelled Ms U’s scan appointment scheduled for 8 July 2019. It acknowledged the HSW should have focused on Ms U’s wellbeing. Having considered Ms U’s second complaint on 16 August 2019, the EPU explained clearly: it accepts it did not extend general information and care to Ms U following her miscarriage.
61. The EPU Lead identified what the HSW did wrong on two occasions. In line with the Ombudsman’s Principles, we expect the EPU Lead to have acted promptly to cancel antenatal appointments for Ms U and arrange wellbeing assessments for her. Because this did not happen, we consider the Trust breached the standards given in the Miscarriage Summary.
62. The Trust’s failings meant that on 16 August 2019, Ms U received a letter from the Trust inviting her to anti-natal appointments. Ms U says this was a brutal reminder of her tragic loss which worsened her mental health.
63. The Trust’s failings also meant it missed multiple opportunities to assess and treat Ms U’s mental health problems. We do not know for sure whether the Trust would have referred Ms U for counselling had it assessed her wellbeing. It seems likely it would have, considering Ms U sought help from a counsellor herself at the end of August 2019.
64. With this in mind, we consider the Trust’s failings worsened Ms U’s distress for around two months. For this reason, we uphold Ms U’s complaint about the Trust’s failure to provide follow-up care. We will consider what we recommend the Trust should do to put this right later in our report.
Complaint handling, final response delay
65. In line with the Trust’s Local Complaints Policy, it aims to respond to complaints with 30, 45, or 60 working days, depending on complexity. It says it will keep complainants updated if its investigation is likely to take longer. It adds, if its investigation is likely to take longer than six months, it will write to the complainant to explain why.
66. In line with the Ombudsman’s Principles, we expect organisations to do what they say they are going to do. If it makes a commitment to do something, it should keep to it, or explain why it cannot.
67. Ms U complained to the Trust on 17 July 2019. It first responded to her 28 days later, on 13 August 2019. This suggests the Trust considered the matters Ms U complained about were not complex enough to require more than its minimum 30 working day time limit.
68. On 14 October 2019, Ms U met with the PALS Lead to discuss her complaint. Ms U says, the PALS Lead agreed to issue the complaint response to her within 30 days or update her if they could not meet this deadline.
69. Neither the Trust nor Ms U recorded the meeting. For this reason, we do not know what was said at the meeting. We know from the Local Complaints Policy it aims to respond to non-complex complaints within 30 working days. This is likely the deadline the PALS Lead set. We reasonably expect the PALS lead to have issued its final response to Ms U by 25 November 2019.
70. The Local Complaint Policy states it will keep complainants updated if its investigation is likely to take longer than stated. Ms U says by 9 December 2019, she had heard nothing from the Trust, which prompted her to email the PALS Lead for an update.
71. The PALS Lead responded on 11 December 2019. They said: ‘Please accept my unreserved apologies but due to pressures within the service your complaint response has not been completed as I had hoped.’
72. The Local Complaints Policy requires the PALS Lead to have updated Ms U at the point they realised they would not meet the deadline, not once the deadline had already passed. For this reason, we consider the Trust did not adhere to the standard it requires of itself under the Local Complaints Policy. We also consider the Trust failed to do what it said it would in line with the Ombudsman’s Principles.
73. Ms U says, the Trust’s unexplained delay worsened her distress.
74. We see on 11 December 2019, the Trust apologised to Ms U for its delay, and explained to her the cause of its delay. We appreciate the Trust’s unexplained delay added to Ms U’s distress. Based on other complaints we have seen, and our severity of injustice scale, we consider the Trust’s apology to Ms U was enough for it to put right the impact this had on her. For this reason, we do not uphold this part of the complaint.