Plans for a homebirth
24. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If we think something went wrong, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so, we have decided the Trust has already done enough to address the complaint.
25. Miss M believes no homebirth plan had been prepared and that the Trust had ignored her concerns about the speed in which she would give birth. We recognise that belief was particularly distressing for Miss M given her previous experience.
26. The Trust said a homebirth care plan was in place, noting Miss M's concerns about the delivery of her previous child. It acknowledged communication around the plan could have been better.
27. NICE childbirth guidance talks about the need to plan a place of birth in advance. It does not specify a need for a written birth plan but accepts some women will have these. It encourages midwives to read such plans and to discuss them with the woman.
28. We saw a midwife completed a personalised homebirth care plan on 3 September 2020. This includes reference to Miss M’s previous rapid labour. Although the midwife has noted (by ticking boxes) lots of areas she discussed with Miss M, the document does not include details of the discussions. This makes it difficult to tell what Miss M understood at the time about what to expect, in particular the possibility a midwife might not be there.
29. Before this on 21 July 2020 a midwife had recorded Miss M’s concerns about her previous experience of labour. This shows the midwife team were aware of Miss M’s previous experience and that she wanted to have a homebirth to avoid another hospital birth.
30. The records available show the Trust planned Miss M’s labour in line with the guidance. We can see the midwife discussed this with her, although we do not know exactly what was said.
31. NMC midwife standards include skills relating to communication. It tells midwives to ‘check understanding’.
32. As Miss M believes there was no plan in place, this suggests a failing in communication. It does not seem the midwife checked Miss M’s understanding, otherwise she would have known there was a possibility a midwife would not be there when she gave birth. There are signs the communication with Miss M fell short of NMC standards.
33. The Trust accepted communication had not been clear when its risk manager reviewed what had happened. It accepted this meant Miss M had not understood it was possible a midwife would not be at the birth.
34. We can see it was distressing for Miss M to think the delivery of her baby had not been planned.
35. Our principles talk about the need for organisations to be open and accountable, and to give solutions that are fair and equal to the problem. This includes compensating people when it is not possible to put them back in the position they would have been in, had the poor service not happened.
36. The Trust offered Miss M £350 to recognise the impact on her. The Trust said it used information from our organisation’s website when deciding on the right amount of compensation.
37. The Trust’s offer is fair and in line with our principles and guidance. We realise Miss M thinks the amount is insulting.
The midwife’s decision to leave Miss M
38. We considered if it was right for the midwife to leave Miss M.
39. NICE childbirth guidance explains what a midwife should do when a healthy woman is in labour, including when to do a vaginal examination. Vaginal examination can help decide if a woman is in established labour.
40. The midwife did a vaginal examination and there was no sign Miss M was in labour at that point. The midwife said she would wait and stayed around another one and a half hours. There was no change during this time. In line with NICE guidance, this meant there was no need for further vaginal examination. The evidence available in the records does not show Miss M was in established labour when the midwife left the house.
41. NICE childbirth guidance says a midwife should give a woman in established labour supportive one-to-one care. It says the midwife should not leave a woman in established labour on her own except for short periods or at the woman's request. As Miss M was not in established labour, it was acceptable for the midwife to leave, even though she had a rapid delivery before.
42. The midwife left Miss M and this was in line with the guidance.
43. Miss M’s situation is similar to a planned hospital birth, where a woman might go when her waters have broken but she is not in labour. The hospital will send the woman home to wait for labour to establish. It is possible in this situation the woman might then give birth quickly at home, without a midwife. Although the intention is for a midwife to be there, this is not always possible or guaranteed. It does not mean the Trust did anything wrong.
44. We can see from the records, the midwife gave Miss M advice to contact the unit if her contractions increased. Miss M confirmed this happened and told us by the time her labour progressed, she did not think there would be time to call the midwife and for her to get there. We understand it was upsetting for Miss M to deliver L without having a midwife there and can appreciate why she feels the Trust let her down. We hope this explanation helps explain what happened.
The clearing of mucus from L’s lungs
45. Miss M is concerned neither midwife cleared mucus from her L’s lungs after she was born. Miss M says midwives did this when she had her son in hospital. We recognise this was worrying for her.
46. The Trust said the World Health Organisation advises against clearing mucus.
47. NICE childbirth guidance does not include recommendations to clear mucus in healthy newborn babies. Our adviser confirmed the suctioning of newborn babies’ lungs has not been routine practice for many years, as evidence shows it causes more damage than benefit.
48. Considering the relevant guidance and the opinion of our adviser, we have seen no signs the Trust should have suctioned L’s lungs. We hope this reassures Miss M that the Trust did not put L at risk.
Delay in doing the NIPE
49. The Trust has apologised for not being able to complete the examination within 72 hours and explained it was due to lack of availability of NIPE-trained midwives. It reassured Miss M the delay had not caused L harm.
50. Guidance in place at the time in Public Health England’s NIPE handbook said the checks should be done within 72 hours. This has since been updated to say it should ‘ideally’ be done within 72 hours, reflecting that this is not always possible. Our adviser said NIPE is usually done within the first 72 hours and, for babies born in hospital, will usually take place before discharge. Our adviser said it is unlikely a baby would come to any harm if a NIPE is not done within 72 hours, if no problem has been identified after the birth.
51. The Trust explained the midwives who carry out these checks must have special training. Our adviser confirmed this is correct. In a community setting, the number of NIPE trained midwives may be fewer than those practicing in the hospital. This may mean that a trained midwife is not always available to attend within 72 hours of a birth. It does not mean a failure in service if a NIPE-trained midwife is not available within 72 hours.
52. We realise Miss M was very upset about the Trust’s suggestion she go to the maternity unit to have the check carried out within 72 hours. She said this would have meant taking her son with her, who was asleep, as she had no childcare. She also felt the suggestion to go to the hospital was wrong because of the COVID-19 pandemic.
53. Miss M described how she felt the staff had pressured her and were annoyed with her when she refused. We can see the Trust was trying to offer a solution and we do not think it was wrong for it to make this suggestion. However, we accept Miss M found the suggestion inappropriate.
54. Although ideally the examination should be done within 72 hours, we do not consider the delay is serious enough to suggest a failing.
The midwife’s check of L’s eyes
55. Miss M says the midwife did not check L’s eyes and so does not believe she checked the red reflex. Red reflex is the normal reflection of white light from the back of the eye. It is seen as a red glow in the pupil when looked at through an instrument to examine the eye. Normal red reflex varies in colour depending on the baby’s ethnicity. Abnormal red reflex can be a sign of cataracts.
56. The Trust said the records show the midwife checked and saw the red reflex and it was the GP who could not see the red reflex at the eight-week check. This led the GP to refer L to secondary care.
57. NICE childbirth guidance says checks done by the midwife shortly after birth will usually pick up anything seriously wrong that needs referral. There are no signs of any problems in this case. The records show L was well.
58. Miss M questions how thoroughly the midwife did the NIPE as the GP reached a different decision when they did their review.
59. The NIPE record shows the midwife checked L’s eyes and saw the red reflex. Had the midwife not seen the red reflex, it is standard practice to make an immediate referral to a paediatrician for onward referral to an ophthalmologist. As the midwife did not make a referral, it supports her seeing the red reflex. It is far more likely that the GP did not see it, leading to them doing the referral.
60. The evidence in the medical records supports the Trust’s account and that it did not find any problems with L’s eyes. Our decision is the midwife did not do anything wrong. We appreciate how alarming it must have been when the GP said they needed to refer L and how worrying the wait was until Miss M got confirmation there were no problems.
Support from midwife following L’s birth
61. NICE childbirth guidance explains what actions the midwife needs to take immediately after the baby’s birth. This includes examining the baby, checking the mother, helping her to shower, breastfeed and making sure she can urinate. Our adviser said this typically takes around two hours to complete. Once this has been completed, providing there are no concerns, the midwife can leave.
62. Our adviser said the midwife may also use professional judgement when deciding when to leave. For example, if the mother was particularly comfortable and wanting to sleep, had breastfed, observations had been done and were within normal limits, the midwife could decide the right time to leave. In this situation, if less than two hours had passed since the baby’s delivery, it would be appropriate for the midwife to leave.
63. The Trust’s homebirth SOP says the midwife should leave, usually within two hours of birth, once mother and baby have been checked. This confirms that midwives are not expected to stay for long.
64. The records show the midwife did everything she should have done. The records show she was satisfied Miss M and L were both well. The midwife had done the required checks and given advice including on breastfeeding, follow up care and who to contact for help. There was nothing more for the midwife to do so it was appropriate for her to leave. Her actions were in line with the Trust’s homebirth SOP and the NICE guidance. Our decision is the Trust did not do anything wrong.
Support with breastfeeding
65. Miss M complains she was ‘fobbed off’ when she asked for help with breastfeeding. She says she rang the homebirth team many times and was panicking because L was not latching on properly. She says she gave up asking for help in the end, said she was fine when asked and got support from a friend. We can see this was a worrying time and naturally, Miss M would have wanted to be confident L was feeding correctly.
66. The Trust said there is no record of Miss M asking for support.
67. Guidance in the NMC Code tells nurses and midwives to keep accurate records. This includes when advice is given. NMC midwife standards talk about the need to promote breastfeeding and to make sure it is effective.
68. We asked our adviser what should normally happen if a woman calls a hospital or midwife to ask for help with breastfeeding. They said it is expected that either:
a) a midwife would provide telephone advice which they would document, in line with NMC guidance, or b) a midwife or other suitably trained member of staff (this might be a midwifery support worker or breastfeeding specialist midwife) would visit the woman (or invite her to a breastfeeding drop-in clinic if one is available). In line with NMC guidance, they would be expected to document the care provided.
69. Our adviser said Miss M would also have been visited after birth by a midwife to do postnatal checks and help with feeding. The records show this happened.
70. The midwife on 2 October 2020 recorded no concerns about breastfeeding. When another midwife visited on 3 October, they documented no concerns with breastfeeding. There was a telephone appointment with a midwife on 5 October, which included a feeding assessment. This also gave no cause for concern. None of the records suggest Miss M raised any concerns on those occasions. We acknowledge Miss M said she gave up trying to get advice and told the midwives she was fine, which may explain why the midwives noted no concerns from Miss M.
71. We could also find no record of Miss M asking for help by telephone. Given the requirements of the NMC on record keeping, it would seem unlikely several different staff members would fail to document Miss M’s calls and the advice they gave. However, we do not dismiss the possibility this happened. Unfortunately, we are unable to say what happened. There is no action we could take to get any more evidence to help explain what happened.
72. We thank Miss M for bringing her complaint to our attention and hope our consideration reassures her that the service the Trust gave her was not different to what would be expected. Where the service fell short, the Trust has offered an appropriate solution.