Established Labour
17. Miss I said just after 11pm she told the Trust her back was hurting. She said she was not given a clear answer about the cause of the pain. She told the Trust at 11.10pm that her waters had broken. She said the Trust did not take her seriously and told her as it was her first labour, it could take 24 hours for labour to begin. Miss I said the Trust told her it was probably the baby kicking. Miss I said she was on the floor in agony and the Trust told her she was in early labour.
18. The Trust said it gave Miss I reassurance and offered paracetamol, which Miss I declined. The Trust said it was documented that Miss I felt her waters break at 11.40pm and it gave her a sanitary pad to monitor the fluid loss.
19. The NICE guidelines define established labour as being when there are regular painful contractions and there is progressive dilation of the cervix from four centimetres.
20. Our adviser explained that signs of established labour are:
• strong regular contractions (about three to four in ten minutes) • dilation of cervix to 4cm or more • the baby moving into the birth canal.
21. Our adviser explained the Propess pessary used for induction of labour is designed to stay inserted for up to 12 hours, or until regular contractions start. There does not need to be any further internal examinations unless it is to remove the pessary, or to check the woman for cervical dilation to confirm labour if there are strong contractions.
22. Miss I said her partner had to chase the doctor for them to review her. He said he had to ask the doctor to remove the pessary because of the level of pain she was in.
23. We can see from the medical records that Miss I reported increasing pain from 11.17pm. At 11.45pm the Trust documented that Miss I was not coping well and was feeling anxious.
24. At 12.50am she was seen by a doctor who recorded she was ‘on the floor on her knees – looking v uncomfortable’. The Trust also documented Miss I said she was experiencing constant contractions. The doctor asked for the pessary to be removed as soon as possible.
25. A midwife documented that Miss I’s contractions seemed to be every one to two minutes and removed the pessary at 12.55am. An examination did not take place until 1.50am.
26. We have found the Trust did not follow the NICE guidelines.
27. Our adviser said had the midwife examined Miss I when she was clearly in pain, they could have identified she was in established labour sooner.
The Trust confirmed Miss I was in established labour at 1.50am on 24 July when a midwife examined her and established her cervix was four centimetres dilated. In line with the NICE guidelines, the examination should have been done at 12.55am when the pessary was removed. This is a delay of at least one hour. We have considered the impact of this failing later in our report.
Pain Relief
28. Miss I said she reported being in pain many times during her labour. She said she was screaming in pain and the contractions were stronger after the pessary was removed at 12.55am.
29. Miss I said she was only offered paracetamol and was not given gas and air until after established labour had been confirmed. Miss I said she asked for an epidural and the Trust told her it was too late as there was no member of staff to give her this. She feels she was not taken seriously by staff who seemed to not believe her pain was as bad as she said.
30. The Trust said the first form of pain relief is paracetamol and if this does not have the needed effect, a stronger pain relief can be given. It said there were staff who could have given stronger pain relief, but they may have been giving care to another patient at the time.
31. The NICE guidelines say if a woman in labour asks for regional analgesia, staff must give this. Regional analgesia is pain management that numbs a large part of the body, like an epidural. This includes women in severe pain in the latent first stage of labour. This is when the cervix becomes soft and thin and starts to open for the baby to be born. This can take hours or sometimes days.
32. Our adviser explained that pain relief options in labour include gas and air (Entonox), and analgesia ranging from paracetamol to opioids (pain relief drugs) like pethidine or diamorphine, and regional analgesia by epidural.
33. Miss I said she first reported pain at 11pm when her back tightened. From 11.17pm, the records show Miss I reported increasing pain. At 11.40pm she reported that she thought her waters had broken and at 11.45pm it was documented she was ‘not coping well, very anxious’.
34. We can see in the medical records that Miss I requested pain relief at 11.45pm and was given paracetamol. A request was sent to the registrar to prescribe dihydrocodeine and the Trust gave this to Miss I at 12.30am.
35. We can see Miss I was reviewed by a doctor at 12.50am. Miss I also reported constant contractions at this time.
36. At 1.40am the Trust documented that Miss I was crying in pain and was encouraged to breathe through the contractions. At 1.50am, Miss I requested an epidural and at 2.03am she started to use Entonox. At 2.30am a midwife inserted a cannula and took blood in preparation for an epidural, while Miss I waited to be transferred to the labour ward.
37. Miss I was transferred to the labour ward at 2.40am and she again asked for an epidural. She was told the anaesthetist was in theatre, but they would get her ready. She requested an epidural again at 3.33am. A midwife prepared Miss I for an epidural at 4am and this was given at 4.50am.
38. Our adviser explained that before the pessary was removed at 12.55am, Miss I had been experiencing uterine hyperstimulation. This is a complication of induced labour where the uterus over contracts. It is clear from both her account and the records that she was already experiencing high levels of pain at this time.
39. Our adviser said they would usually expect a second anaesthetist to be available to give an epidural. Our adviser also said the records should give more information on the reasons for the delay and that this had been explained to Miss I. Our adviser said the Trust could have offered Miss I an opiate painkiller.
40. We have found the Trust failed to recognise Miss I was in established labour and this led to a delay in her being transferred to the labour ward. If she had been transferred sooner, we think it is likely she could have had an epidural sooner.
41. In total, it was five hours from Miss I first asking for pain relief to when the epidural was done. During this time, she was not offered opioid analgesia. She was also not offered Entonox for over three hours. She was clearly in pain throughout this time and during the first hour she was experiencing uterine hyperstimulation.
42. Based on the evidence, we have found the Trust did not offer Miss I effective pain relief in line with the NICE guidelines. The Trust should have offered Miss I Entonox sooner than it did. It should also have offered an opioid painkiller. There is no documentation in the records that these were offered when they should have been. We have considered the impact of this later in the report.
Visiting
43. Miss I said her partner left the Trust at 9pm. Miss I said she asked the Trust to call her partner to return later that evening because of the high level of pain she was in. She said staff told her that he needed to be home resting. Miss I said she was scared and alone. Miss I insisted the Trust call her partner but it told her she had to call him herself.
44. The Trust said there is no reason staff could not have contacted Miss I’s partner on her behalf. The Trust apologised that Miss I’s partner was not with her and accepted that having a partner present offers support to patients and helps to reduce anxiety and fear.
45. Our ‘Principles of Good Administration’ say organisations should treat people with sensitivity, bearing in mind their individual needs and respond flexibly to the circumstances of the case.
46. Our adviser said there is no reason Miss I’s partner could not be there, particularly as she had known mental health problems.
47. The Trust said it did not have a visitor policy at the time. It told us that visiting hours on the maternity observation ward were from 10am to 10pm.
48. We can see in the medical records Miss I asked her partner to return to the ward at 11.50pm. The Trust did not document the conversations it had with Miss I about this. In the complaint information the Trust did not dispute what happened and it apologised to Miss I. It is documented that her partner arrived at the ward at 12.45am on 24 July.
49. From the evidence we have seen, we have found the Trust did not act in line with our Principles. The Trust should have considered Miss I’s mental health and allowed her partner to return when she asked. It should have contacted Miss I’s partner for her. We have looked at the impact of this failing below.
Impact
50. Miss I said she has flashbacks and the events have had a negative effect on her mental health. Miss I said she was prescribed anti-psychotic medication after the events at the Trust. She says she has experienced severe distress and pain.
51. Our adviser explained if the Trust had recognised Miss I was in established labour, she would have been given one to one midwifery care. It seems the failing we have found meant Miss I did not get the support she should have.
52. We appreciate how the Trust not recognising she was in established labour and giving support would have affected Miss I’s anxiety, particularly when considering her mental health. We also understand how this would have caused Miss I more distress at an already challenging time.
53. We know Miss I said she was prescribed anti-psychotic medication and we asked our adviser about this. We are unable to say whether the failings we found can be linked to this. We appreciate Miss I may be disappointed by this.
54. Miss I said she was in agony and felt the Trust did not take her pain seriously. Miss I said the trauma and distress she experienced has caused a lot of built-up anger.
Our adviser says the Trust not giving appropriate pain relief in good time would have been traumatic and Miss I would have been in unnecessary pain and distress.
55. We understand this was an extremely emotional and upsetting experience for Miss I. We also understand this would have been frightening for Miss I as she was alone. Unfortunately, we are unable to say how much this would have affected her mental health.
56. Miss I says she did not have the opportunity for her partner to be with her at the beginning of labour and she was terrified without him there to support her. She says not only was it extremely traumatic to be in that situation alone, but this is a time that was taken away from them and she thinks about this every day.
57. We understand the impact this had on Miss I and the added distress this caused.
Recommendations
58. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.
59. We have considered the impact caused by the Trust not recognising Miss I was in established labour, not giving appropriate pain relief in good time and not allowing her partner to be with her. We cannot link the more serious claimed impacts such as the decline in her mental health or her loss of earnings to these failings.
60. Our Principles for Remedy say organisations should quickly identify and accept maladministration and poor service, and apologise. An apology means accepting the failure, taking responsibility for it, explaining clearly why it happened and expressing sincere regret for any injustice caused.
61. We recommend the Trust writes to Miss I within one month of our final report to accept the failings we have found and to apologise for the linked impact. We ask the Trust to send us a copy of this letter.
62. Our Principles for Remedy say that organisations should look for continuous improvement. Organisations should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service.
63. We recommend the Trust provides details of the actions it will take to address these failings. It should make an action plan setting out what it has done or intends to do to stop similar events from happening again. The action plan should explain who is responsible for the action, when it will be completed by and how it will monitor the changes to make sure there is improvement.
64. The Trust should make the action plan within three months of our final report and share this with Miss I, us, the Care Quality Commission and NHS Improvement.
65. Our principles say that 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.
66. To decide on a level of financial compensation, we review similar cases where the person has experienced similar injustice and we use our severity of injustice scale. Our scale allows us to make sure the recommendations we make are consistent and transparent for everyone who uses our service.
67. We recommend the Trust pays Miss I £875. This is in recognition of the pain, distress and fear Miss I experienced as a result of the failings we have identified.