Pain relief
34. Miss O says that the clinical staff did not discuss pain relief options with her or explain what medication they were giving her. We have considered what should have happened, in line with the relevant guidance, and compared this to Miss O’s account and what the clinical notes show the staff actually did.
35. Our Midwifery and Obstetrics Advisers both explained that there is no national guidance on the management of second trimester miscarriages. However, our Midwifery Adviser confirmed that the standards set out in the Second Trimester Miscarriage guidance for the North West of England reflect what good care should look like. They also explained that the midwives should have ensured the care they provided met the professional standards set out in the Code and ensured the pain relief was in line with NICE Guideline CG190.
36. The Second Trimester Miscarriage guidance states that ‘it is good practice to have an early discussion about what to expect in terms of . . . analgesia’. It also states that ‘adequate analgesia should be offered’ and ‘all usual modalities should be made available’. Our Midwifery Adviser explained this means that Miss O should have been offered all the pain relief options available to a woman delivering a child at full-term.
37. NICE Guideline CG190 (sections 1.8.11 and 1.8.12) sets out what pain relief should be available to women delivering a child at full-term. This guidance states that Entonox and opioid-based pain relief should be available in all birth settings. This should have been available to Miss O during her miscarriage.
38. The Code (7.3) also states that midwives should communicate with patients to better understand, and respond to, their personal and health needs. In this context, the midwives needed to communicate with Miss O on an ongoing basis about her pain relief needs. This was especially important because these would likely change as her miscarriage progressed. This discussion should have included an initial conversation about the full range of pain relief available, and there should also have been an ongoing dialogue regarding pain relief. All discussions regarding pain relief should have been documented, in line with the Code (10).
39. The clinical notes contain no record of any discussion with Miss O, relating to her pain relief options. Miss O’s account of what happened also reflects this. Given there is no documentation these discussions took place, and Miss O says they did not, our view is that the midwifery staff more likely than not failed to discuss or review pain relief options with Miss O. This falls so far short of the Second Trimester Miscarriage guidance and the Code that it amounts to a failing in the care provided to her.
40. With regards to whether the midwifery staff explained what medication they were giving her, our Midwifery Adviser explained that the Code expects midwives to:
· make sure that they get properly informed consent and document it before carrying out any action · encourage and empower people to share in decisions about their treatment and care · keep clear and accurate records of this.
41. The midwives should have explained to Miss O the drugs they were administering including the risks, benefits, and potential side effects. This is important for identifying any potential allergies or drug sensitivities, and also for enabling choice and consent. In order to give informed consent to any medication, it was essential for the midwives to discuss this with Miss O first. The midwives should also have documented these discussions clearly.
42. There is no documentation from the clinical staff of any discussion with Miss O about the medications she was given. This means staff either did not discuss these with her or did not document the discussion(s) they had. Miss O’s account is that the staff did not explain what medications they were giving her. The Trust has accepted this did not happen in its response to her complaint, as there is nothing documented to indicate this happened. Therefore, we find that, on balance, it is more likely than not staff failed to inform Miss O what medications she was being given. This falls far short of the Code, and it is a failing in the care given to her.
43. Miss O explains that failing to discuss her pain relief options and the medication given to her caused her distress and led to her experiencing physical pain for longer than she should have.
44. It is difficult to know whether Miss O would have experienced less pain than she did, had staff discussed her pain relief options with her, or reviewed these as her labour progressed. This is because childbirth is usually painful, even when pain relief is managed optimally.
45. Despite the difficulty in knowing whether the failings identified could have led to Miss O experiencing more pain that she should have, we have reached a decision on the balance of probabilities.
46. We know that Miss O, more likely than not, experienced a high degree of pain. We know that her pain was increasing from 12.30pm on 1 April, and that she was offered opioid-based pain relief twice that afternoon.
47. Miss O’s account of what happened reflects that both times she was given opioid-based pain relief it worked for a short-time, but then she continued to experience a lot of pain. The British National Formulary’s (BNF) guidance for administering dihydrocodeine is 30mg every 4-6 hours, with a maximum dose of 180mg within a 24-hour period. The BNF’s guidance for pethidine during childbirth is an initial dose of 50-100mg, followed by 50-100mg after 1-3 hours – a maximum of 400mg in a 24-hour period.
48. Midwifery staff administered 60mg of dihydrocodeine, orally, at 12.30pm. While outside single dose guidance in the BNF, this was well within the maximum dose within a 24-hour period and was in line with the doctor’s prescribing instructions. Staff could not have administered more of this drug until 4.30pm at the earliest. However, midwifery staff had already commenced administering stronger pain relief before that time.
49. The Shift Co-Ordinator gave Miss O 100mg of pethidine via intramuscular injection at 2.45pm. This drug could have been followed by further injections to relieve pain from 3.45pm, as required. Miss O says the injection at 2.45pm helped in the short-term but that afterwards she experienced the ‘worst pain of [her] life’. There was a period of over an hour where Miss O could have been offered further opioid analgesia but was not.
50. According to the BNF’s guidance on the use of Entonox, this can only be used while supervised by a clinician, such as a midwife, and so this could only have been used while staff were available. Given the staffing shortages faced by the labour ward at that time, it is unlikely the Entonox could have been offered much sooner than when it was given, at approximately 5pm.
51. Both our Obstetrics Adviser and our Midwifery Adviser have explained that Miss O’s increasing pain needs indicated her labour was progressing, especially following the administration of pethidine at 2.45pm. There was a window of opportunity, between 3.45pm and when she miscarried at 5pm, to provide further pethidine to relieve her pain. During this time, Miss O reports experiencing the worst pain of her life and was asking for help with this. No further pain relief was offered during this time. Therefore, we find that, on the balance of probabilities, the lack of discussion or review of Miss O’s pain relief needs were a missed opportunity to provide more pain relief at that time.
52. Given Miss O reports the first pethidine injection reduced her pain, it is more likely than not that that further pain relief could have reduced the pain and discomfort experienced both in the hour preceding, and at the point at which she miscarried her daughter. On balance, this oversight meant she experienced more pain during this time than she would have done had she had her pain relief needs reviewed appropriately.
53. Given Miss O probably experienced more pain than she should have, it follows that she, more likely than not, experienced more distress than she would have done, had her needs been better managed. We can also understand that being given medication without an explanation could have been very distressing for her at this time.
54. The Trust has acknowledged that the Shift Co-Ordinator did not explain the medication Miss O was given and has apologised for this. However, it has not acknowledged it could have managed her pain relief better, nor has it taken steps to put right the impact this had on Miss O. Therefore, we have made recommendations to the Trust in order to put this right.
Communication
55. Miss O complains that staff communicated poorly with her about what to expect while experiencing a second trimester miscarriage.
56. Our Midwifery Adviser explained it is vital parents are fully informed about what to expect during a second trimester miscarriage, as set out in the Second Trimester Miscarriage Guidance. This means that the staff caring for Miss O should have welcomed questions from her and provided her, and her partner, with written information about what to expect. Written information and the opportunity to ask questions are important, as the traumatic nature of a miscarriage means that some parents struggle to retain information conveyed to them verbally.
57. The Second Trimester Miscarriage guidance also states that, although staff should take care not to ‘overload’ parents with information, they should be given adequate information about what to expect. They should also be included in discussions about management options, with their wishes taken into account. It is good practice to have an early discussion about what to expect in terms of induction, pain relief, delivery, appearance of baby, memory boxes, and other mementos.
58. The Good Medical Practice guidelines (paragraph 49) state that doctors must ‘work in partnership with patients’ and provide the information they will need to make decisions about their care. The guidance states this should include telling people about: ‘their condition, its likely progression and the options for treatment, including associated risks and uncertainties’.
59. The clinical notes reflect that the SPR noted a miscarriage was likely but that a cervical stitch may be possible. However, there is no documentation to indicate how much of this was discussed with Miss O. Our Obstetrics Adviser explained that given this clinician knew the ‘full facts’ at this early stage, they should have engaged Miss O in a discussion about this. There is no evidence for this in the records, meaning this fell short of the Good Medical Practice guidelines.
60. Once Miss O arrived on the labour ward, there is nothing documented to show that she, or her partner, were given any verbal or written information about what to expect with regards to pain relief, the appearance of her baby, or any mementos she may wish to keep.
61. There is some indication Miss O was told, verbally, that she would need to deliver vaginally, as she says that she was given a choice about whether she wished to deliver her daughter ‘naturally’. It is also documented in her clinical notes, on 31 March, that she was told her child would not survive. However, there is nothing documented to indicate staff had any detailed discussion with her about what to expect while having the miscarriage.
62. The clinicians’ communication about what to expect fell far short of the applicable guidance.
63. The notes show that Midwife 1 asked Miss O if she understood the information conveyed during the ward round consultation at 11am on 1 April, and whether she had any questions. However, the notes of what actually took place during this consultation are incredibly sparse, and the midwife did not document whether Miss O had any questions or whether she understood the information she had been given. Therefore, on balance, this does not adequately demonstrate Miss O was given enough information about what to expect, or that staff made sure she understood this.
64. The evidence shows that the clinical staff either failed to give Miss O the information she needed or failed to document this. Given Miss O’s account of not being told what to expect, on balance, it is more likely than not that staff failed to have these discussions with her.
65. Failing to provide Miss O with adequate information about what to expect during her second trimester miscarriage falls so far short of the Good Medical Practice guidelines, the Second Trimester Miscarriage guidelines, and the Code, that this was a failing in the care provided to her.
66. Miss O told us that the failure to provide her with all the information she needed about what to expect caused her a lot of distress. She explained that this was because she did not know what was happening, what was going to happen, or whether her daughter would survive.
67. We can certainly understand that the uncertainty Miss O experienced during this time would have been incredibly distressing for her. A miscarriage is an incredibly traumatic experience by itself, and it is completely understandable that a lack of information could have compounded this.
68. It is documented that clinicians told her that her baby likely would not survive, but this was not until four hours after our Obstetrics Adviser identified that clinicians should have had a frank, detailed discussion about this with her. It is also understandable that the traumatic nature of the experience may have made it less likely that Miss O could retain, process, and understand this information when it was given. This is why it was so important that the clinical staff had ongoing discussions with her about what to expect and checked that she understood her child could not survive. A failure to do this would reasonably cause any parent a lot of distress and uncertainty about what would happen.
69. The Trust has acknowledged that Miss O’s complaint ‘highlighted important concerns’ and that it has ‘strengthened and implemented changes’ following it. It has acknowledged that her overall experience, was likely distressing. However, it has not addressed the impact outlined in Miss O’s complaint to the Trust, which was the distress at not knowing what to expect. The Trust has also not explained how it will improve its service in future. While we credit the Trust with acknowledging its service fell short, and its clear attempt at addressing this empathetically, it has not done enough to put right the impact of what went wrong. Therefore, we have made recommendations to address this.
Lack of support and observation from midwives
70. Miss O complains that the midwifery staff left her alone for long periods of time, when it was not appropriate, and did not respond to her requests for help. She says as a result, she miscarried her daughter alone, with no support from midwifery staff.
71. Our Midwifery Adviser explained that it is not unusual for a woman to deliver a child suddenly during a second trimester miscarriage. However, they also explained that the midwives should have been observing and monitoring the progression of her miscarriage to indicate when Miss O may deliver her child. Our Midwifery Adviser explained that this is part of midwives’ responsibilities set out in the Code, which expects midwives to:
· accurately identify, observe, and assess signs of normal or worsening physical and mental health in the person receiving care · maintain effective communication with colleagues · keep colleagues informed when they are sharing the care of individuals with other health and care professionals and staff · keep clear and accurate records relevant to practice.
72. This means that the midwifery staff caring for Miss O should have been actively assessing and observing the progressing signs of labour, documenting this, and communicating the progression of her labour to all clinical staff responsible for her care at that time. Our Midwifery Adviser also explained that Miss O should have been the midwives’ priority for compassion and support as her miscarriage progressed towards delivery.
73. The clinical notes made by the midwives show Miss O was reporting increasing pain and needing pain relief from 12.30pm on 1 April. However, while the administration of medication was documented, the midwifery staff did not document any assessment of her abdominal pain, or whether she was having contractions. They did not check if her waters had broken, and they did not document any contact or communication with her for long periods of time, in between providing pain relief.
74. Our Midwifery Adviser explained that at 2.45pm Miss O began reporting severe pain and the Shift Co-Ordinator gave her opioid based pain relief. They explained this should have indicated to the midwives that delivery may be progressing closer, however, no assessment of this was documented.
75. Miss O was not seen by a midwife again until just before 5pm, when Midwife 2 introduced herself. Our Midwifery Adviser explained that this midwife should have received a full handover of the details of Miss O’s care from the Shift Co-Ordinator. However, the evidence shows this likely did not happen as they had to leave Miss O alone in order to familiarise themselves with her care. It was at this time she miscarried her daughter without support from midwifery staff.
76. We have found that midwifery staff missed a number of opportunities to check and/or document the progression of Miss O’s miscarriage. We have also found that, on balance, the midwifery team did not communicate with each other effectively regarding her care. This falls so far short of the standard of care set out in the Code it is a failing in the care provided to Miss O.
77. Miss O says this experience was incredibly traumatic for her and says she felt neglected. She also explained that this experience affected her mental wellbeing afterwards and caused anxiety regarding attending hospital when she became pregnant again.
78. While the miscarriage would have been distressing by itself, we can entirely understand that feeling unsupported during this time and miscarrying her child onto the floor of a hospital, without clinical support, would have compounded that distress.
79. We can also understand that the impact of this poor care likely worsened the impact the miscarriage had on her mental wellbeing. In addition, we acknowledge that her experience on the labour ward caused her anxiety about attending hospital when she became pregnant again.
80. We were pleased to see that the Trust fully acknowledged that ‘this should never have happened’ and apologised sincerely. It has also ‘strengthened’ its processes to alert the senior management team of staffing difficulties, so that all women in labour can receive one to one care.
81. While the Trust has gone some way to putting things right, and we do appreciate that April 2020 was likely an incredibly challenging time in terms of staffing due to the pandemic, our view is that it has not done enough to put right the impact of what happened to Miss O. This is because it has not acknowledged how incredibly distressing this experience would have been, nor has it considered how it should put things right. Therefore, we have made some further recommendations to put this right.
Mortuary services
82. Miss O complains that the mortuary service at Hospital A did not inform her about the funeral for her daughter, and that the Trust buried her without her family present. She adds that when she asked the mortuary where her daughter was buried, it provided the wrong plot number. This meant that when she attended the cemetery she could not find where her daughter was buried.
83. The function of arranging Miss O’s daughter’s funeral was an administrative one for Hospital A. Our Principles of Good Administration (our Principles) provide a framework for public bodies, which set out what good administration looks like. In line with our Principles, the mortuary service should have:
· communicated effectively with Miss O · treated her sensitively, bearing in mind her individual circumstances · provided an effective service that was easy to access · ensured any information it gave her was clear, accurate and complete
84. Miss O’s daughter arrived at the mortuary on 7 April 2020. At this time many mortuary services were becoming overwhelmed by the deaths from the first wave of the COVID-19 pandemic. We have considered this context when considering whether its service fell short, and what it should do to put things right.
85. On 24 April, Miss O informed the mortuary that she and her partner would like Hospital A to arrange the funeral on their behalf, and to bury her daughter. She asked for the details of the funeral and grave because she wanted to erect a plaque at a later date. However, the mortuary told her that it could not provide details due to delays caused by the COVID-19 pandemic.
86. On 28 April, the Trust booked a funeral for 1 May. It sent a letter to Miss O on 29 April to inform her of this. Miss O never received this letter, and the Trust has confirmed that ‘some of the letters that were posted around this time were not delivered’.
87. We can see the Trust wrote to Miss O to inform her of the date of her daughter’s funeral, which demonstrates it did attempt to communicate this to her. It sent the letter on 29 April to inform her of an important funeral which was to take place on 1 May. This allowed just two working days for the letter to be sent, processed by Royal Mail, delivered, opened, and for the parents to both emotionally prepare themselves and make arrangements to attend the funeral. Two days is an incredibly short time period to complete these actions, particularly in the context of the early pandemic when postal services were running slower than usual.
88. Furthermore, by only informing them of the funeral by post, with just two days’ notice, this short notice meant there was a serious risk of the parents not receiving this crucial letter. For example, they may have been staying with friends or family at that time, or there may have been delays with the postal service. Any of these could easily, and foreseeably, have led to them missing the funeral due to the short notice given, even if the family had eventually received the letter. Our view is that the short notice regarding the funeral meant the service was not easy to access and was not sufficiently sensitive to her bereavement.
89. Given the short notice to attend the funeral, it is unclear why the Trust chose only to write to Miss O with these details, which was the slowest way for it to inform her about the funeral. This is especially as all prior contact with her had been by telephone, and it was aware she had a working voicemail facility. The mortuary service had previously contacted her via telephone and left voicemails, and she had returned its calls in a timely manner. Therefore, the Trust knew this was a viable way to contact her and that she could access any messages it left for her.
90. It would therefore have been a simple administrative task to call Miss O after arranging the funeral to advise her of the date and time, following the letter being sent. If she did not answer, it could have left a voicemail. This would have gone a long way to communicating with her effectively, and ensuring the service was easy for her to access. We do not think the impact of the COVID-19 pandemic could have reasonably prevented it from calling Miss O, however, the Trust did not call her to ensure she knew when the funeral would be.
91. We have found that the mortuary service’s decision to inform Miss O by post that the funeral was due to take place in two days’ time, without following this up, falls so far short of our Principles of Good Administration that it amounts to a failing.
92. With regards to where her daughter is buried, the Trust has accepted it initially provided Miss O with the wrong plot number for her daughter. Our view is that this falls short of ensuring the information the Trust gave her was accurate. On its own, this may not be a failing in the service provided to Miss O. However, in the context of the fact the Trust had already failed to effectively communicate the date of the funeral to Miss O, this matter further added to the poor administration of her daughter’s burial. Therefore, this was a further failing in the service provided to Miss O.
93. Miss O explains these administrative oversights, relating to the burial of her daughter, compounded the distress and trauma of losing her daughter. We can entirely understand how these oversights furthered her distress.
94. The Trust has fully acknowledged the ‘error and oversight’ on the part of the mortuary service, and we were pleased to see it also acknowledged how distressing this was for Miss O and apologised for this. While this does go some way to putting things right, our view is that the Trust has not yet done enough to put this right. Therefore, we have made further recommendations.