Portsmouth Hospitals NHS Trust

5. Mrs C complains the Trust did not give her appropriate care during her visit to its ED on 17 June 2021. She explains she was just under five months pregnant and was having cramp-like pain in her lower abdomen every five to ten minutes. She says she was told a gynaecologist would come to see her, but she waited hours and was not seen or moved to a bed or room.

6. She says she went to the toilet and had a miscarriage. She questions how this happened and why the gynaecologist did not come. She says the Trust said it was a miscommunication.

7. Mrs C thinks things could have been different if she had been seen and examined quickly. She tells us she is frustrated and feels her questions have not been answered. She says she was not able to prepare herself emotionally and mentally for her loss because she was not examined.

8. Mrs C says she had to call in sick and take a lot of time off work because of being traumatised. She says she eventually decided to leave work as it reminded her of when she was pregnant. She says she became homeless and lived with a friend. She also explains it put a strain on her marriage.

9. She wants financial compensation for the distress she has experienced.

10. Mrs C had lower abdominal pain on 16 June 2021. She was approximately five months pregnant and had experienced no issues with her pregnancy. She says this was her first pregnancy, so she was unable to identify the pains she was experiencing and did not know what they may mean.

11. Mrs C initially waited before seeking help as she had also experienced pain the day before and hoped it would go away. But the pain only increased, so she asked her GP for help on 17 June 2021.

12. Mrs C called her GP, who advised her to call the 111 service about the pain she was experiencing. The 111 service is a non-emergency telephone service which can help patients identify what medical care they need and what steps to take. After considering her symptoms, the service booked an appointment for her at the Trust’s ED and advised her to go to the hospital as her pain had increased.

13. Mrs C says she went to hospital on her own, without her husband, because of COVID-19 measures.

14. Mrs C arrived at the Trust’s ED at 5pm on 17 June 2021. The ED nurse navigator, who is intended to be a single point of contact for patients, advised Mrs C she would be referred to a gynaecologist because she was pregnant. She was seen by an ED doctor at 7.25pm. They assessed her, took some blood for testing and repeated that a gynaecologist would see her. Mrs C had a pain score of eight out of ten. She remained in the ED waiting room at this time.

15. After waiting a few more hours, the ED doctor returned to take more blood for testing and to give fluids to Mrs C. They informed her the gynaecologist had declined to review her and had referred her to the general surgical team.

16. Mrs C remained in the ED waiting room on the understanding the surgical team would see her. After a few more hours, she felt the need to go to the toilet. Sadly, she had a miscarriage in the toilets of the ED waiting room. We recognise this experience must have been incredibly distressing for Mrs C.

17. At 11.45pm, doctors were alerted to what had taken place in the toilet and told nurses so they could assist Mrs C. The nurses helped Mrs C onto a trolley and saw she needed further medical attention as the placenta had not come out.

18. Mrs C was transferred to a gynaecology ward to receive support and aftercare. Her husband was called and allowed on the ward to provide support.

22. Mrs C says when she attended the ED she waited for hours to see a gynaecologist and was not given a room or bed. She tells us she was left not knowing what was happening, even though she had told the Trust she was five months pregnant. We have considered whether the Trust acted in line with applicable guidelines and standards in deciding how best to manage Mrs C’s needs when she attended the ED.

23. The evidence we have seen from Mrs C’s clinical records tells us a pain score of eight out of ten means her pain was classified as severe. Our ED adviser explains the standard recommendation for a patient with severe pain is to see them within 60 minutes of their arrival at the ED. The records indicate the Trust, including the gynaecological team, were aware Mrs C was five months pregnant and they planned to see her within 30 minutes.

24. GMC guidelines say, ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must […] promptly provide or arrange suitable advice, investigations or treatment where necessary.’

25. The records tell us the Trust was aware of the need for urgent care. But, following the initial review, it did not then act in line with the relevant clinical guideline for reviewing pregnant patients.

26. The Trust has accepted it did not give Mrs C a good standard of care in its ED in relation to the review that should have followed. In its response to Mrs C’ complaint, it accepted a gynaecologist should have reviewed her in line with the Second Trimester Miscarriage guidance. Although the Trust is in a different geographical area to the authors of the guidance, our clinical advice confirms this standard applies to this case. It says, ‘Clinical examination should include the woman’s vital signs and careful abdominal examination assessing for any uterine tenderness. Sterile speculum examination should be performed by a trained individual in an appropriate environment, ensuring the woman’s privacy and dignity.’

27. As this review did not take place, we consider this to be a failing in care. We have thought about the impact of that failing, including whether a gynaecologist review could have resulted in a different clinical outcome.

28. Mrs C tells us she thinks the outcome of her pregnancy could have been different if she had been seen and examined quickly, in line with guidelines. Our gynaecology adviser explains in an out-of-hours setting, such as when Mrs C went to hospital, a patient may expect to be seen and examined, including a vaginal speculum examination, as part of the review referred to in the Second Trimester Miscarriage guidance. Out-of-hours ultrasound scanning (a procedure using high-frequency sound waves to create an image of part of the inside of the body) is not universally available. As Mrs C went to the ED on a Thursday evening, she would normally have had a scan the following day. But this would not have changed the outcome.

29. The miscarriage appears to have happened because of chorioamnionitis (an infection of the fluid and membrane surrounding the baby during pregnancy), as shown on the pathology report (a document explaining what is visible in cells and tissue). This leads to the uterus (womb) expelling the pregnancy. We understand from our gynaecology adviser a speculum examination would likely have shown that the cervix (the opening between the vagina and the womb) was opening and that might have warned the Trust and Mrs C about a possible miscarriage. The only action which can be taken in the case of the cervix opening at this point in the pregnancy is to insert a suture (a stitch) around the cervix to keep it closed. Even if this had been done, the miscarriage would still have happened.

30. As such, overall, we have not seen anything to lead us to conclude Mrs C’s miscarriage could have been avoided, even if the Trust had not made the mistake we have identified. We hope this reassures her we have not seen anything, in our independent assessment, to suggest the outcome might have been different for her and her baby as we know this issue has caused her distress.

31. In our view, the Trust’s failure to examine Mrs C was a missed opportunity. It failed to identify that she was having a miscarriage, to manage her expectations about what was happening and to ensure she was given swift support, in line with applicable guidelines and standards. In the evidence available to us, we can see the miscarriage could not have been stopped if Mrs C had been examined. But the Trust would have been able to explain to her she was having a miscarriage and settle her in a more appropriate setting, that is, on a ward with greater comfort and privacy. Mrs C would have been better informed and prepared about what was happening. We can see this was a lost opportunity for improved support, communication and comfort.

32. The NICE guideline explains clinicians should, ‘Treat all women with early pregnancy complications with dignity and respect. Be aware that women will react to complications or the loss of a pregnancy in different ways. Provide all women with information and support in a sensitive manner, taking into account their individual circumstances and emotional response […] Healthcare professionals providing care for women with early pregnancy complications in any setting should be aware that early pregnancy complications can cause significant distress for some women and their partners.’

33. GMC Good Medical Practice guidelines also say that clinicians should ‘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’.

34. These guidelines tell us good communication, dignity and respect are important in pregnancy complication cases. Sensitivity is important due to the significant distress the pregnant woman will very likely be experiencing, and thought should be given to the care setting. We cannot see evidence of good communication and appropriate management of care in Mrs C’s case until after she had had her miscarriage and been transferred to a ward.

35. We are very sorry to hear about the miscarriage and fully recognise this has been an extremely difficult time for Mrs C. We have thought about what would put things right for her.

36. Our gynaecology adviser tells us it is known miscarriage in the middle months of a pregnancy can lead to long-term psychological distress, even if the care and treatment provided are in line with guidelines. It is not unusual for anyone who has a miscarriage to require additional support and care to overcome the psychological trauma and its effects.

37. As the Trust could not have stopped the miscarriage and it did not happen because of a failing in its care, we are not looking to put right the longer-term impact the miscarriage has had on Mrs C. We are sorry to hear how badly this affected her employment, personal relationships and housing, and, while we cannot say the Trust’s error caused these difficulties, we do not intend to belittle Mrs C’s experience.

38. In our view, the avoidable impact of the Trust’s error on Mrs C was she was not mentally or emotionally prepared for the possibility of a miscarriage.

39. It would have been a very difficult time for Mrs C. It was her first pregnancy and she was not able have her husband with her at the hospital because of COVID-19 measures. In our view, it would have been very worrying and upsetting to not know why the gynaecologist did not review her or what was physically happening to her before and during the miscarriage, when she was left alone without appropriate explanations and reassurance. Our gynaecology adviser says if a gynaecologist had reviewed Mrs C, she would very likely have been transferred to a gynaecology ward, where she would have been supported by staff trained to care for distressed patients in such situations.

40. Mrs C tells us she accepts the outcome may not have been any different but, as she was not examined and informed about what was happening, it has left a question in her mind as to whether the miscarriage might have been avoided.

41. We have looked at how Mrs C has suffered the injustice of having a question left in her mind and the uncertainty this has caused her. The Trust says it was highly unlikely it would have been able to stop the miscarriage even if it had done a gynaecology review.

42. We have looked at what the Trust has done to put right the impact on Mrs C. We can see the Trust accepts its failure to give Mrs C a gynaecological review, apologises for this and is implementing improvements to its service. These improvements include:

• Junior doctors in the ED will be given further training on how to refer to specialty registrars so they are not referred to another specialty against their better judgement.

• Specialty registrars will be instructed not to refer on to another specialty without first seeing the patient.

• Mrs C’s complaint will be anonymised and shared with members of staff in the ED and gynaecology departments so that lessons can be learned and in the hope similar situations can be avoided in future.

43. We welcome the above proposals from the Trust and are glad to see it is taking appropriate steps to learn from these events. But it has not yet put things right for Mrs C, so we make the recommendation outlined below.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs C’s complaint about Portsmouth Hospitals NHS Trust (the Trust). We are very sorry to hear of her experience and the distress and upset she describes.

2. This is a sad case involving an unexpected miscarriage and we hope reading it does not cause any Mrs C any undue distress.

3. We have identified failings as the Trust’s gynaecology service did not review Mrs C when she attended the emergency department (ED). This means Mrs C was left waiting in the ED where she later suffered a miscarriage in the toilets. We can see there was a missed opportunity to fully prepare Mrs C for the loss of her baby due to the lack of a review. She tells us she did not understand what was happening and had to deal with the severe distress of that experience in an undignified setting without appropriate professional support or care.

4. We can see the Trust has taken the complaint seriously and recognised it made mistakes in the service it provided to Mrs C. But, in our view, the Trust has not yet taken appropriate steps to put right the emotional impact on Mrs C because of its mistakes. So, we partly uphold this complaint and recommend the Trust pay Mrs C £950.

44. In considering our recommendation, we have referred to our Principles for Remedy. These say where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.

45. Our Principles for Remedy say public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, they should compensate them appropriately.

46. To decide on a level of financial compensation, we review similar cases in which a person has experienced a similar injustice, along with our severity of injustice (SOI) scale, which is set out in our Guidance on Financial Remedy.

47. Following this review, we can see the impact on Mrs C is at level 3 of our SOI as the impact of the distress caused at the time of these events was significant. We also recognise the longer period of uncertainty and distress she has experienced not knowing whether the miscarriage could have been avoided. As such, our view is that the Trust should pay Mrs C £950. It should make this payment within three months of the date of our final report.