Lack of compassion and rushed into making a decision
17. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect that the organisation has not put right. Having considered this, we think the Trust has already done enough to put right the impact of what happened.
18. Mrs R told us the Trust rushed her into making a decision about whether she wanted to have medical or surgical management of her miscarriage. She said she felt as though the Trust did not deliver the news about not having a viable pregnancy in a suitable way.
19. We discussed this with our adviser. They told us the NICE guidance is relevant. This guidance advises that during discussions, patients should be allowed enough time so that decisions do not feel rushed. It also says an individualised approach should be used by healthcare services which is tailored to the patient’s circumstances.
20. Our adviser explained what this guidance means should have happened in this case. They said there was no medical reason not to give Mrs R time to consider her options. They said, ideally, she should have been given enough time to think about her options before making a decision.
21. The Trust accepted in its complaint response that Mrs R felt the diagnosis of a miscarriage was not given sensitively and that Mrs R felt pressured to make a decision on how her miscarriage would be managed.
22. Having discussed this with our adviser and considering all the evidence, we think the Trust did not act in line with the NICE guidance. It seems the Trust did not provide the information that Mrs R needed when considering her state of mind.
23. We recognise the impact this had on Mrs R. Her counsellor provided us with information about her experience based on a phone call Mrs R made to them while she was in the hospital. The counsellor describes how Mrs R was extremely tearful and very distressed, compared to her calm and capable usual self.
24. We have carefully considered what the Trust has done to put right what it got wrong and how this affected Mrs R. We can see it accepted that its communication was not sensitive, and it apologised that she felt rushed into making a decision. It also apologised for the distress this may have caused Mrs R. The Trust explained it has spoken with several of the staff involved to address the issues.
25. Our principles say to put things right organisations should, ‘acknowledge mistakes and apologise where appropriate, provide prompt, appropriate and proportionate remedies considering all the relevant factors of the case when doing so’.
26. Our principles also say organisations should seek continuous improvement. They say organisations should, ‘ensure that all feedback and lessons learnt from complaints contribute to service improvement.’ And they should, ‘ensure they: • tell the complainant when lessons have been learnt as a result of their complaint • state any changes they have made to prevent the problem recurring.’
27. We can see that the Trust have acted in line with our principles by acknowledging and apologising. The Trust has also addressed the communication issue with several of the staff involved. We believe this was an appropriate response to her complaint and in line with what Mrs R wanted. Based on this we do not think we would achieve more for Mrs R and we will not consider this part of the complaint further.
Leaflet pack and lack of IVF understanding
28. Mrs R complains that after she was diagnosed with a miscarriage, the Trust offered a support pack containing leaflets which were unsuitable for IVF patients. Mrs R said these leaflets contained information which were complete contradictions for IVF patients.
29. This was because the leaflets advised patients that they could become pregnant again in 30 days. Mrs R says she was only offered information specific to her circumstances when she discussed this issue with the clinic, who posted this information out to her.
30. Mrs R also told us that during her appointment with the Trust for the surgical procedure on 12 April, staff did not tailor their communication to suit her situation as an IVF patient. She says this means staff showed a lack of understanding around IVF.
31. During this appointment, Mrs R says a nurse spent 30 minutes explaining that she would have a ‘miracle baby’. She also says she was told many times that she would be able to get pregnant again in a matter of months. Mrs R advised us that this round of IVF was her final one and was the last embryo they had.
32. Section 1.1 of the NG126 NICE guidelines say, ‘all women should be provided with information and support in a sensitive manner, taking into account their individual circumstances and emotional response. In addition, healthcare professionals should, where appropriate and with consent, provide women with a variety of information including where to access support and counselling services, including leaflets, web addresses and helpline numbers for support organisations.’.
33. The Trust acknowledged giving Mrs R the wrong leaflets. It advised Mrs R had spoken with a member of staff about this matter. It said as a result of this conversation, the staff member confirmed there is a supply of leaflets titled ‘Miscarriage and Infertility’ that has now been added to the ‘miscarriage packs’ and can be given to ladies who experience a miscarriage after fertility treatment.
34. The Trust also acknowledged the comments made by the staff member involved in Mrs R’s care on 12 April and offered its sincere apologies. The Trust advised that the staff member would be spoken to by management about the lack of appropriateness of the conversation.
35. Having discussed this with our adviser and considered all the evidence, we think the Trust did not act in line with NICE guidance in ectopic pregnancy and miscarriage and in patient experience.
36. It seems the Trust did not take Mrs R’s individual circumstances into account with the information it provided in the leaflets. It seems the Trust did not communicate with Mrs R in an individual way that was appropriate to her.
37. This situation caused Mrs R and her husband much distress because they had been trying for a baby for the last four years.
38. We have looked at what the Trust has done to try and put things right for Mrs R and if this is enough. As we have explained above, the Trust’s complaint response acknowledged the failings in these areas and it has apologised.
39. But, we have not seen that the Trust has apologised in writing for the impact the leaflets had on Mrs R. But, we understand Mrs R spoke directly to a member of staff and got some assurance from that.
40. We have thought carefully about this. We recognise a written apology for the impact would be best practice complaint handling. But, we can see the Trust has acknowledged the problem with the leaflets and seems to have taken steps to stop this happening again.
41. Overall we consider the Trust’s responses to these issues to be in line with our principles of good complaint handling. We consider the response to be an appropriate service improvement. Based on this we have not seen signs that we would achieve more if we were to investigate this further.
Medical management of miscarriage at home
42. 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 seen any signs that something has gone wrong with this part of the complaint.
43. Mrs R says the Trust should have admitted her to the ward sooner after the medical management on 18 March. She says the Trust would then have been able to examine her for retained pregnancy as she was showing several symptoms of a molar pregnancy.
44. The NHS website describes a molar pregnancy as, ‘when there’s a problem with a fertilised egg, which means a baby and a placenta do not develop the way they should after conception. A molar pregnancy will not be able to survive. It happens by chance and is rare.’
45. She says she discussed the symptoms with doctors from the Trust over several phone calls. Mrs R says that, due to the Trust not taking her symptoms seriously and stating they were psychosomatic (a physical reaction to a mental or emotional issue), she had to rely on the clinic to give her the care she needed.
46. Mrs R listed the symptoms she was experiencing in her diary, and we have seen copies. Some of the symptoms she mentioned include strong and persistent nausea, excess saliva, food aversion and dizziness. We understand that Mrs R had a traumatic and painful experience, and we are sorry for the impact this had on her.
47. Mrs R’s counsellor has confirmed in a letter that her experience with the Trust has ‘hugely impacted her mental health’ and Mrs R is still having treatment with her counsellor to address the effect this had.
48. Our adviser highlighted that Mrs R reported that she had passed a pregnancy sac the same day as she had the treatment at the Trust. They say that this is likely to confirm that there has been a complete miscarriage.
49. NICE NG126 guidelines say:
• ‘1.5.17 - Provide women and people who have had medical management of miscarriage with a urine pregnancy test to carry out at home 3 weeks after medical management of miscarriage unless they experience worsening symptoms, in which case advise them to return to the healthcare professional responsible for providing their medical management.
• 1.5.18 - Advise women and people with a positive urine pregnancy test after 3 weeks to return for a review to the healthcare professional responsible for providing their medical management to rule out a retained pregnancy, molar or ectopic pregnancy, and assess the need for further investigations or treatment.
• 1.5.19 - If the pregnancy test after 3 weeks is negative but the woman or person is still bleeding heavily or has other symptoms (for example, pelvic pain or fever), then assess the need for further investigations or treatment’.
50. Our adviser explained, in line with this guidance, a pregnancy test three weeks after treatment should be done.
51. Our adviser also said Mrs R’s medical records show that the Trust prescribed the right medication and gave her advice about what to do if her symptoms got worse or if she had any concerns.
52. In the time after her discharge, Mrs R had several phone calls with the EPU to discuss her symptoms. She had a phone call with EPU ten days after treatment where ongoing symptoms and management of these were discussed. We have noted this was still within the three-week timeframe after medical management of miscarriage.
53. We have also seen it is written in the medical records that Mrs R declined to attend EPU when the Trust offered this on 5 April. Instead, a blood test with her GP was arranged and a plan was agreed. This plan was to see Mrs R in EPU between 8 and 9 April. Mrs R contacted the clinic on 9 April, it arranged a scan and diagnosed that Mrs R had retained products of conception (RPOC is an incomplete miscarriage).
54. Having discussed this with our adviser, our view is the Trust had no opportunity to diagnose or manage RPOC. This is because Mrs R did not attend when it offered to see her.
55. It is clear that Mrs R had lost confidence in the Trust and we are sorry for how she felt during this time. We are not commenting on her decisions about her care. We are simply considering the evidence to see if the Trust followed guidelines.
56. Having considered all the evidence, we think the Trust acted in line with NICE guidance. Evidence shows Mrs R knew how to contact the Trust to discuss how the management was progressing. And when she did, the Trust offered for her to come back in so it could assess her.
57. All of the events were within the three-week timeframe that NICE guidance recommends. When Mrs R did come back to the Trust, it provided the surgical management the private clinician recommended.
58. There is no evidence that Mrs R did not get the correct treatment for her RPOC or that the Trust did not follow the medical management of miscarriage at home guidelines. We have seen no signs of failings with this issue and we are not taking further action for this reason.
59. We recognise Mrs R’s complaint is important to her. We also recognise it relates to a very sensitive issue and a very difficult experience for her. We hope our explanations are helpful and not too distressing for her to read.