Ashford and St Peter's Hospitals NHS Foundation Trust

5. Mrs A complains about the actions of staff at the Trust after the birth of her children on 1 October 2020. She complains:

• a midwife incorrectly referred her to social services • a midwife made inappropriate comments and questioned her when she was feeling weak and upset.

6. As a result of the midwife’s actions, Mrs A says:

• her symptoms of postnatal depression worsened, and she found the first year of being a mother extremely difficult • Trust staff made her believe she would not be able to parent her children.

7. Mrs A wants the Trust to make a payment to her in recognition of the injustice she has suffered.

8. The Trust began giving Mrs A antenatal (during pregnancy) care on 27 August 2020, after another Trust transferred her. She was 28 weeks pregnant at the time.

9. On 1 October, Mrs A was admitted to hospital at 35 weeks pregnant with preeclampsia (a blood pressure condition affecting pregnant mothers). She gave birth that day by caesarean section (a cut made in the tummy and womb). Staff transferred her children to the Neonatal Intensive Care Unit (NICU, a unit which cares for babies who require a higher level of care after birth).

10. Around 6pm on 2 October, the records state Mrs A was ‘exhibiting uncharacteristic behaviour’ and was ‘distraught and inconsolable’. The records state she ‘has not shown any signs of harming her or anyone else but her behaviour has changed acutely’. A midwife referred her to the Trust’s postnatal psychiatric team (a team specialising in mental health).

11. On 3 October, the records show Mrs A was feeling better after resting. She got out of bed, washed and had something to eat for the first time since giving birth. The psychiatric liaison team assessed her at 11.30am. The records show Mrs A was reluctant to respond because she believed the psychiatric liaison team would judge her parenting skills.

12. On 4 October, staff told Mrs A her children could be taken to a transitional care unit (a unit which allows for resident mothers to be with their children while receiving additional care and support). Staff noted Mrs A was ‘disconnected’ and ‘anxious’. The records show she explained to staff that she felt weak and upset but was willing to work with the staff to find somewhere to stay with her children where she would feel safe.

13. The records show that, later that day, a midwife spoke to Mrs A about the safeguarding process. Mrs A told the midwife she understood the safeguarding process, but felt it did not apply in her case. She explained to the midwife that she thought she was only struggling to cope because of her difficult birth experience.

14. The midwife noted that they planned to ask the perinatal mental health team to do an assessment and for a doctor to review Mrs A to see whether they could discharge her to recover at home.

15. On 5 October, the records show Mrs A told staff she felt much better after getting some sleep and was looking forward to being at home with her children. The Trust discharged Mrs A that day.

16. On 6 October, Mrs A came to hospital because she found it hard to breathe. Staff suspected deep vein thrombosis (a blood clot in a vein) and the records show Mrs A ‘became very distressed at the thought of staying in hospital’. She was admitted to a ward at 6.40pm.

17. On 8 October, the records show Mrs A told a midwife she was feeling very anxious about staying in hospital with her children after her experience the week before. Records from the next day show she was feeling well and was planning to move to ‘a family room on NICU…with babies prior to discharge’.

18. Social services called Mrs A’s husband on 12 October. They explained that a Trust midwife had made a safeguarding referral. The records show Mrs A was ‘distraught’ when she heard about this.

19. Later that day, Mrs A spoke to the Trust’s lead safeguarding midwife, who told her the midwife should not have referred her to social services because there were no safeguarding concerns in her case. The midwife explained that they had contacted social services to try and cancel the referral.

20. The Trust discharged Mrs A on 15 October.

Referral to social services

23. Section 6 of the Trust’s safeguarding policy states staff should make a referral to social services when they believe or think:

• a child is suffering or is likely to suffer significant harm • a child’s health or development may be impaired [damaged] without the provision of services, or • with the agreement of the person with parental responsibility, a child would be likely to benefit from family support services.

24. The same section of the Trust’s policy also explains the process for referral to social services. It says:

• the staff member should discuss the reasons for referral and […] be open and transparent and gain consent [permission, from the parent]. If consent is not obtained, the staff member would need to clearly document the reasons consent has not been sought • in hours [9am to 5pm] seek advice from your line manager or the safeguarding team, safeguarding advice available via Trustnet – safeguarding children pages. Out of hours advice can be accessed via the emergency duty team • consent can be overridden [not accepted] if it is felt that the threshold of significant harm or by discussing the sharing of information places them at further risk of harm [to the parent or child] and • copies of the referral are to be uploaded [added] to both mother and babies’ hospital medical notes.

25. Mrs A complains a Trust midwife incorrectly referred her to social services after the difficult birth of her twins. She feels the referral was not necessary because there were clear reasons for the difficulties she was experiencing, and because she says staff reassured her the referral would not happen.

26. She told us she found the birth of her twins painful and very difficult, and she had been struggling to breathe at the time. She explained that she had drifted in and out of consciousness and thought she was dying. We are sorry to hear how difficult and distressing this experience was for her.

27. Following the birth, Mrs A told us she felt she would not be able to manage. She explained that she was in a daze, had a panic attack and worried she would not be able to care for her children. The Trust moved Mrs A to an antenatal ward, where she said a midwife she did not know took over her care.

28. She told us the midwife came in to speak to her when she was in an emotional state on 4 October. She explained that the midwife was ‘judgemental’ and told her she was worried about the safety of the children.

29. She explained that the midwife generally discussed the safeguarding process with her. She says she found out later, after social services called her husband on 12 October, that the midwife had made a safeguarding referral. Mrs A explained that this severely affected her mental health.

30. The Trust told us the health professionals on duty at NICU were concerned for Mrs A’s welfare, as she had a concerning event during a visit to see her children. The Trust said the midwife was worried about how Mrs A would cope with constant crying, feeding and changing nappies, because caring for newborn twins can be very tiring.

31. The Trust recognised the midwife should not have referred Mrs A to social services, because it was not necessary. It explained that the midwife failed to get advice from the Trust’s specialist safeguarding team before making the referral. The Trust also explained that the midwife did not appear to consider Mrs A’s whole birth experience and the impact it had on her. It apologised to Mrs A for this.

32. The Trust explained that the midwife had thought about this. She said she was concerned about the health and happiness of Mrs A and the babies and just wanted to make sure they were all okay.

33. The Trust’s policy is clear: staff should get advice before making a safeguarding referral, get the parent’s consent for the referral (except in some circumstances) and clearly record the referral.

34. None of these things happened. The Trust has accepted the midwife did not get advice before making the referral, and we have seen no record of them doing so.

35. There is also no evidence that the midwife asked for Mrs A’s consent for the referral or even told her about it. We can see no clear reasons in the records why the midwife should not have asked for consent.

36. It is clear Mrs A had been experiencing mental health difficulties before the referral. But we do not think asking for consent for referral would have put Mrs A or her children at risk, because Mrs A had already discussed the safeguarding process with the midwife without getting distressed, and because the children were in the NICU at the time.

37. In fact, the records show the discussion that a referral would not be made reassured Mrs A. The records show she explained why she had been struggling and why she felt the process would not apply to her. There is no record the midwife then told her they would make the referral anyway, only that they planned to involve mental health staff and to ask doctors to review her before discharge. We can see that Mrs A was ‘happy with this plan’.

38. We can also see no record of the referral in Mrs A’s medical records.

39. Following a review of the records, it is clear the referral would not have reached social services if the midwife had processed it through the correct channels. We can see that a member of the Trust’s safeguarding team contacted social services to try and cancel the referral shortly after Mrs A told them about it.

40. The safeguarding midwife explained to Mrs A that the referral was not needed because ‘we do not have any safeguarding concerns and it appeared what she had experienced was due to significant sleep deprivation [lack of sleep]’. The same midwife then explained this to social services the next day.

41. We can see from the records that the midwife who made the referral was concerned about Mrs A’s health and happiness and how she would manage to care for her children. We can see why the midwife would think this, because Mrs A’s mental health had changed and she had displayed some uncharacteristic behaviour.

42. But we cannot see clear evidence to suggest Mrs A’s children were suffering, or were likely to suffer, significant harm. The records show Mrs A was struggling after the birth, but, on the day of the safeguarding discussion, Mrs A was ‘more alert and calm’ and was ‘enjoying time with the babies’. A midwife who saw her at 6.26pm wrote ‘I am less concerned for her mental health from this conversation’.

43. We can see that Mrs A was happy with the staff’s plan for her to spend more time with her children. We can see no clear sign that referral to social services was needed to prevent impairment to the children’s health or development.

44. We understand the midwife thought they were acting in the best interests of Mrs A’s children, but we can see that they did not follow Trust policy but made the referral incorrectly without getting advice first or making accurate notes.

45. We have decided the midwife’s actions fall so far short of the Trust’s policy as to be a failing. The records show Mrs A was in a weak and emotional state, but the midwife did not consider all the reasons for this before making the referral or let Mrs A know they were doing this.

Inappropriate comments

46. Paragraph 20.5 of the Nursing and Midwifery ‘Code’ says staff must ‘treat people in a way that does not take advantage of their vulnerability or cause them upset or distress’.

47. Mrs A told us the midwife who made the referral asked her about ‘weird’ scenarios to decide if she was having difficulties with her children. She told us she got angry with the midwife at this point, who she believed should not have been judging her parenting skills when she was so weak and emotional.

48. She told us the midwife told her she may have postpartum psychosis (a serious mental health illness affecting someone soon after having a baby) as a ‘friend of hers had it’ and she recognised the symptoms. She also told us the midwife explained that, as Mrs A was a teacher, she would struggle more as ‘teachers are used to routine and babies do not work like that’.

49. Mrs A said she was not given the opportunity to explain how she was feeling and had a ‘disconnected feeling’ during the conversation.

50. As a direct result of the words and actions of the midwife, Mrs A told us her symptoms of postnatal depression worsened after discharge from hospital. She told us she still often thinks about the words the midwife used and finds them difficult to deal with.

51. The Trust says the midwife explained that she mentioned her friend’s experience to reassure Mrs A that postpartum depression was a common condition which could be managed with support. The Trust says the midwife has accepted that sharing personal experiences may not be appropriate.

52. The Trust explained that the midwife should not have shared personal experiences. It said discussing Mrs A’s ability to cope was not acceptable and it does not expect any professionals to communicate or make such judgements.

53. We have reviewed the records and cannot see any notes showing the midwife mentioned her friend’s experience or saying Mrs A might struggle more because she was a teacher. During the complaints process, we can see that the midwife accepted she mentioned her friend’s experience.

54. We understand the midwife may have thought she was reassuring Mrs A that her condition was common, and we cannot see any clear evidence that she meant any harm in how she said it. We recognise Mrs A does not agree, but we do not think we can say this clearly based on the evidence we have (the complaint responses, Mrs A’s account and the records).

55. But we have decided it was not appropriate for the midwife to share this personal experience, considering the difficult time Mrs A had experienced and the distress she was in at the time. We consider this falls short of the NMC Code, as it was likely to cause Mrs A more distress.

56. We cannot decide whether the midwife told Mrs A she would struggle to cope because she was a teacher or questioned her on strange scenarios. We recognise Mrs A’s account and accept that, just because the conversation is not noted in the records, does not mean it did not happen. But, overall, we do not feel we have enough information to decide whether this conversation happened.

Our view on the impact on Mrs A

57. We think the Trust’s midwife made an incorrect referral to social services and failed to follow the NMC Code in their conversations with Mrs A. In considering the impact this had on Mrs A, it is important to first consider her circumstances at the time.

58. The records clearly describe the distress Mrs A experienced because of the difficult birth and during her stay on the ward. We also note she was unable to receive full support from her husband at this difficult time because of COVID-19 restrictions on visitors.

59. So we can see why hearing about the safeguarding referral (despite feeling reassured it would not happen) would have made her distress worse, would have made her feel more emotional and would have made her feel that staff were questioning her ability to parent. We can also see that the midwife’s comments about her friend’s experience would have caused her more distress.

60. Mrs A told us she suffered badly with her mental health when she was discharged and that her symptoms of postnatal depression worsened as a direct result of the midwife’s words and actions.

61. She said social services had contacted her husband, which added a lot of anxiety and stress at a difficult time. She also told us she experienced more stress because she worried a social services referral would affect her work as a teacher working with children.

62. We cannot say for sure the midwife’s actions alone made Mrs A’s postnatal depression worse or her first year of motherhood more difficult. We can see how her traumatic birth experience, and other experiences in hospital which the midwife was not involved in, might have contributed to this.

63. The records show Mrs A was already experiencing significant difficulties with her mental health before she spoke to the midwife and found out about the referral.

64. However, we recognise these caused her more anxiety and distress, and made her feel staff were questioning her ability to parent. We will make recommendations for the Trust to put this right.

1. The Parliamentary and Health Service Ombudsman has decided to partly uphold Mrs A’s complaint. We have identified that Ashford and St Peter’s Hospitals NHS Foundation Trust (the Trust)’s midwife did not follow guidance when they made a safeguarding referral (when staff are worried someone is experiencing, or is at risk of, abuse or neglect). We have also found they did not follow guidance in their conversations with Mrs A.

2. We recognise the emotional impact this had on Mrs A at an already difficult time. We are sorry to hear about her difficult birth experience and how what happened afterwards worsened her distress.

3. We do not think the midwife’s actions alone made Mrs A’s postnatal depression (when parents feel depressed after having a baby) worse, so we will partly uphold the complaint.

4. We recommend the Trust make a financial payment of £1,250 to Mrs A in recognition of the emotional impact the actions of the Trust had on her at an already difficult time.

65. In considering our recommendations, we referred to our ‘Principles for Remedy’. These state where a failing has had an impact on someone, the organisation responsible should put things right.

66. Our ‘Principles for Remedy’ state 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. Mrs A wants the Trust to make a payment to her in recognition of the injustice she suffered.

67. To decide on a level of payment in recognition of the injustice suffered, we review similar cases where the person has experienced similar injustice, along with our ‘Severity of injustice scale’.

68. Level four of our ‘Severity of injustice scale’ includes cases that had a significant and/or lasting impact on the person affected beyond ordinary distress or inconvenience. We consider this to be the appropriate level of payment in recognition of the injustice suffered in this case.

69. This is because we can see that the incorrect safeguarding referral likely had a significant impact on Mrs A, both at the time (because of her difficult experience giving birth) and for some time afterwards (because of her job as a teacher).

70. We think the midwife’s comments would have caused more distress at the time, although less than hearing about the referral, but we do not think either of these failings alone made Mrs A’s postnatal depression worse.

71. We have decided the Trust should pay Mrs A £1,250 in recognition of the significant distress and anxiety she experienced because of the failings we have identified. We recommend the Trust do this within two months of the date of this report. We recommend the Trust write to us to confirm when it has made the payment.

72. We recognise this was a very distressing experience for Mrs A. We wish Mrs A and her family all the best. We hope Mrs A feels this report answers her complaint.