University Hospitals Bristol and Weston NHS Foundation Trust

3. Ms O complains about the maternity care provided to her from the Trust during her first pregnancy in 2020. She complains the Trust failed to diagnose Vasa Previa at her 32-week pregnancy scan on the 21 September.

4. Ms O says because of this, her baby’s life was put at risk, and she had to have an emergency caesarean section. She feels if the Trust had diagnosed Vasa Previa earlier it would not have been as stressful and traumatic, and she would have had longer to come to terms with the diagnosis before the birth. She says she has been emotionally and psychologically affected.

5. By bringing this complaint to us, Ms O would like the Trust to:

• acknowledge that it should have diagnosed Vasa Previa • make improvements in the maternity services, sonography department, and training for the sonographer to diagnose life threatening conditions at the earliest opportunity • review whether her case was a one off, or whether there is a possibility Vasa Previa, and other life-threatening conditions for unborn babies, have been missed in other cases.

6. Vasa Previa is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

7. Ms O experienced bleeding in the early stages of her pregnancy and was diagnosed with a low-lying placenta at around 19 weeks gestation.

8. On the 21 September a 32-week gestation ultrasound was performed, to check placental site. Ms O’s placenta was found to be posterior low (as had been indicated earlier in the pregnancy) measuring 9mm from the internal cervix opening. The doctor advised rescanning for placenta localisation at 36 weeks.

9. Ms O then moved address and was referred to a different hospital Trust. Her consultant sent a letter to the new hospital Trust giving the results of her 32-week scan. It recommended a further scan at 36 weeks to plan for mode of delivery, requesting the new Trust to take her ongoing care and provide an urgent review. The new antenatal department sent Ms O an appointment for 19 October.

10. She attended the new Trust and had another scan at 36 weeks gestation where she was diagnosed with Vasa Previa and taken for emergency c-section.

Care and treatment

14. Before we decide if we should investigate 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. We have done this and, we have not found any indications something went wrong.

15. Ms O says the Trust failed to diagnose Vasa Previa at her 32 week pregnancy scan on 21 September. She believes staff need training on how to diagnose Vasa Previa. She believes there was a higher chance of her getting Vasa Previa because of the bleeding she had earlier in her pregnancy, and her diagnosis of a low-lying placenta. She believes Vasa Previa does not develop in pregnancy and is present from the beginning of the pregnancy. She is concerned that the Trust is not providing safe levels of care to other women and babies.

16. She says an earlier diagnosis was possible, which would have allowed her more time to come to terms with the diagnosis, meaning the birth would have been planned and not as stressful and traumatic.

17. During our assessment of Ms O’s complaint, we considered clinical advice which we obtained from an obstetrician, with reference to the relevant clinical standards.

18. We looked at the most relevant guidelines from the RCOG green top guidelines, 27a “Placenta Previa and Placenta Accreta: Diagnosis and Management” and 27b “Vasa Previa: Diagnosis and Management”.

19. While there is a higher risk of having Vasa Previa when there is low lying placenta and bleeding, the RCOG guidelines does not recommend screening for Vasa Previa. This is partially because the evidence is limited, includes small numbers, and some is from other countries.

20. The RCOG Vasa Previa guideline states: “vaginal bleeding in pregnancy could be considered as a possible alert symptom for Vasa Previa but has only a very low positive predictive value given the high prevalence of bleeding during pregnancy and the rarity of Vasa Previa.”

21. Our adviser explained a lot of women have bleeding in early pregnancy. Ms O had bleeding up to 13 weeks in her pregnancy. This is common and not necessarily related to Vasa Previa. Not all women with bleeding have Vasa Previa but women who have Vasa Previa more commonly have bleeding.

22. Vasa Previa is serious but rare. The RCOG Vasa Previa guideline 27b recommends delivery between 34 and 36 weeks in asymptomatic Vasa Previa. Ms O had already reached 36 weeks when she was delivered so had only just passed this timeframe.

23. RCOG Vasa Previa guideline 27b says: “there is insufficient evidence to support universal screening for Vasa Previa at the time of the mid-pregnancy routine fetal anomaly scan in the general population”. It states: “although mid-pregnancy ultrasound assessment of pregnancies at higher risk of Vasa Previa have a high positive predictive value, further research into the risk and benefits is required”.

24. RCOG Placenta previa guideline 27a says “In women with a persistent low-lying placenta or placenta previa at 32 weeks of gestation who remain asymptomatic, an additional TVS is recommended at around 36 weeks of gestation to inform discussion about mode of delivery”.

25. It is good practice, but not a national requirement, for all women with a low-lying placenta to have a transvaginal scan at 32 weeks. Ms O says that the Trust did a transvaginal scan at 32 weeks gestation. This is good practice. Such a scan would have made it more likely for Vasa Previa to be identified. However, tests can miss a condition.

26. The Vasa Praevia guidelines states: “a mid trimester 20-week scan has a high diagnostic for Vasa Previa but does not recommend this as national screening. There are concerns about false negatives as well as the acceptability of an invasive test for a large number of women, for a low prevalence condition”. The Vasa Previa guidelines say more research is needed in this area. The Trust identified the low-lying placenta at 20 weeks. National guidelines recommend rescanning at 32 weeks and 36 weeks, which the Trust did (or recommended to be done when Ms O changed Trust). Ms O had asymptomatic Placenta Previa therefore the recommendation is to have another scan at 36 weeks, which the Trust did.

27. Our Principles of Good Administration say public bodies should provide effective services, using appropriately trained and competent staff. A trained sonographer who is able to do transvaginal scans can do the test for Vasa Previa. RCOG Vasa Previa guideline 27b states “The performance of ultrasound in diagnosing vasa previa at the time of the routine fetal anomaly scan has a high diagnostic accuracy with a low false positive rate” and “A combination of both transabdominal and transvaginal colour Doppler imaging (CDI) ultrasonography provides the best diagnostic accuracy for vasa previa.” These tests can be done by a sonographer, but often these cases are referred to fetal medicine teams for confirmation of the diagnosis due to the impact the diagnosis will make on a woman’s antenatal care.

28. The person who performed Ms O’s 32-week scan was a trained sonographer and therefore, able to test for Vasa Previa. Following the scan, the results were discussed with a Consultant Obstetrician who advised rescanning for placental localisation at 36 weeks. This plan was acceptable as the placental edge was no longer reaching the opening of the cervix into the uterus.

29. We have considered the response from the Trust, which states, Ms O was seen by a Consultant Obstetrician at 29 weeks gestation following the growth scan. There was no obvious indication for an earlier consultant appointment. The consultant made a plan to see Mrs O at 36 weeks for a further growth scan, however, Ms O moved to a different area prior to this appointment. A consultant also contacted the Obstetric department at the new Trust on the 5 October to inform them that Ms O was transferring to their care at 34 weeks gestation and had a posterior low-lying placenta. The consultant recommended a further assessment of the placenta site at 36-37 weeks gestation to make the appropriate plan for delivery. Ms O received the 36-week scan at the new Trust, as planned.

30. Ms O had bleeding for up to 13 weeks in her pregnancy. This is common and not necessarily related to Vasa Previa. There was no indication at that time that a test for Vasa Previa was required.

31. The Trust diagnosed Ms O’s low-lying placenta at 20 weeks. The Trust has acted in accordance with the National guidelines, which says to re-scan at 32 and 36 weeks. They recommended the 36-week scan with the new Trust, and this took place at the new Trust.

32. As Ms O had asymptomatic Placenta Previa, the Trust correctly recommended a scan at 36 weeks.

33. The Trust has followed the appropriate guidelines, given the progress of Ms O’s pregnancy, and we therefore find that the Trust did what it should have done and there is no indication of failings in the care provided.

1. We have carefully considered Ms O’s complaint about University Hospitals Bristol and Weston NHS Foundation Trust (the Trust). We have seen no indication the Trust did anything wrong or missed an opportunity to diagnose Vasa Previa, during the later stages of Ms O’s pregnancy.

2. We are sorry to hear Ms O’s concerns about the care she received from the Trust. We appreciate Ms O had a stressful and traumatic birth, and we are sorry to hear about her difficult experience.