Failure to offer pain relief in labour
15. To decide if we should do a detailed investigation of a complaint, we look at what outcome the person wants to resolve their complaint. We can resolve a complaint without doing a detailed investigation if we can deliver the outcomes wanted at an earlier point in our case handling process.
16. Mrs O says she asked many times for pain relief and the midwives did not give her any. She says this led to her labour being traumatic and causing her distress. She needed the involvement of the perinatal mental health team when she had her second child, to help her with the anxiety that this first experience created.
17. In the Trust’s complaint response, it said there were delays in giving pain relief because it needed to do and interpret a CTG (a cardiotocography monitors the baby’s heart rate and mother’s contractions in labour).
18. Our adviser told us NICE guidance CG190 is relevant to this care. It says: ‘Ensure that pethidine, diamorphine, or other opioids are available in all birth settings. Inform the woman that these will provide limited pain relief during labour and may have significant side effects for both her (drowsiness, nausea, and vomiting) and her baby (short-term respiratory depression and drowsiness which may last several days).’
19. Mrs O’s medical records show that staff gave paracetamol and dihydrocodeine (an opioid painkiller) at 8.30am. She had diamorphine (a strong painkiller) at 10.35am. At 3.20pm she asked for more pain relief. After this, there was an unexplained 28-minute gap before starting the CTG. There was no documentation about why the midwives had not given pain relief and it was not referred to again until 5.18pm when Mrs O was using Entonox (gas and air).
20. Our adviser noted Mrs O could have had another dose of diamorphine. If a decision was made not to give this due to the effects on the baby’s breathing, NICE guidance says this should have been discussed. This does not seem to have happened. Mrs O told us the midwives never gave her a reason for not being given pain relief.
21. The evidence we have seen suggests the Trust did not meet the standards set out in the NICE guidance. This is a sign of a failing.
22. We approached the Trust with our clinical advice. It said the 28-minute delay is unclear and not documented. There was a conversation at 3.20pm about Entonox, but there is no evidence for the reasons why Mrs O was not suitable for alternative options. The Trust accepts this is a failing and said it would like to apologise for this and for the distress the pain caused.
23. We understand this failing most likely meant Mrs O had more pain during her labour. Mrs O says the trauma experienced led to her having a termination the next year. In July 2023 she gave birth to her second baby. The perinatal mental health team gave support to her during this pregnancy. The notes state that her concerns about labour were affecting her ability to enjoy pregnancy and affecting her sleep. This evidence shows that Mrs O experienced the impact she described.
24. Our 'Principles for Remedy’ say, ‘Where maladministration [fault] or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately.’
25. We reviewed our severity of injustice scale (a tool we use to look at how someone has been affected and what an appropriate payment for this would be) and consider Mrs O’s injustice sits at level three (£500-£950). The impact on Mrs O fits with level three emotional injustice cases that are described as: ‘Distress, upset or worry lasting 6-12 months. Significant distress (that is, distress which results in a degree of functional impairment) lasting from a few weeks to three months (or shorter periods where the symptoms are greater). Single traumatic or highly distressing experiences where there was no other significant adverse impact’.
26. We spoke to the Trust and explained what we had found. The Trust agreed to offer a payment of £750. We told Mrs O about this and she is pleased with the outcome.
27. Mrs O’s desired outcomes were an apology, acknowledgement and a financial payment. The Trust has agreed to provide these outcomes, which are in line with our Principles. We are satisfied the Trust’s actions will be enough to achieve a resolution for this part of her complaint.
Failure to listen when concerned that she needed cervical checks
28. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong with this issue.
29. Mrs O says the Trust failed to listen when she was concerned that she needed cervical checks. She says this failure contributed to the impact of a traumatic experience during labour. Mrs O said the midwives should have examined her every four to five hours, but she only had two examinations. One of these was when she first arrived and the second was when she was asking for pain relief.
30. The Trust agreed in its complaint response that examination should take place every four to five hours, but this is once a woman is in established labour. It said that staff had not confirmed Mrs O to be in labour until 4.15pm, so it did the correct number of examinations.
31. NICE guidance says: ‘offer a vaginal examination four-hourly or if there is concern about progress or in response to the woman's wishes.’
32. Our adviser explained the NICE guidance relate to established labour. The medical records support the Trust’s explanation that this was not confirmed until Mrs O was examined at 4.15pm. Our adviser explained there is no guidance on frequency of examination in the latent phase (the phase before established labour), but it is reasonable to offer this when the mother wants it.
33. We have seen in the medical records that a midwife examined Mrs O within an hour of her request for pain relief at 3.20pm. Having discussed this with our adviser we understand this was a reasonable timeframe because Mrs O was not in established labour.
34. A midwife examined Mrs O in response to her request for pain relief and the guidance does not suggest she needed an examination any earlier. We have not seen any signs of failings with this part of the complaint.
Failure to offer induction when her waters broke
35. 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 done so we have found the Trust has already done enough to put right the impact of these events.
36. Mrs O said staff told her during her recent pregnancy that the Trust should have offered her induction of labour when her waters broke. Mrs O was known to have group B streptococcus (GBS is a type of bacteria that is usually harmless but can cause a problem in pregnancy). She said that finding this out heightened her feelings about the poor care and caused more distress.
37. The RCOG Green top guideline 36 says: ‘Women who are known GBS carriers should be offered immediate IAP (intrapartum antibiotic prophylaxis) [treatment for GBS] and induction of labour as soon as reasonably possible.’
38. We have noted that at 1pm the medical notes say, ‘for transfer to maternity ward and await augmentation’. Our adviser explained that if immediate augmentation was not possible (speeding up the labour), then staff should have discussed this with Mrs O and documented it clearly.
39. The Trust said it could not transfer Mrs O to the delivery suite for augmentation due to activity on the ward. It stated that staff followed the guidelines but they did not communicate this effectively to Mrs O and this was a failing in communication.
40. Our adviser explained the reason for offering augmentation is to reduce the baby’s risk of exposure to GBS. Mrs O’s baby did not get GBS and so there has been no clinical impact from this poor communication. It is understandable that Mrs O would feel frustrated knowing this part of her care was below the expected standard. We can see how this would affect the impact of her overall complaint.
41. Our severity of injustice scale categorises a level one injustice as when: ‘The person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases.’
42. Mrs O was not aware of this failing at the time. Having thought about this carefully, we do not think that a financial payment would be appropriate.
43. The Trust has recognised its poor communication and apologised. The Trust has acted in line with our Principles to put things right. We can see no evidence of an injustice that still needs to be but right.
Failed to listen to her husband when he raised concerns about bleeding
44. Mrs O had a PPH after giving birth. She says her main concern throughout her experience was the poor communication and the feeling that no one was listening to her. She says this contributed to her overall poor experience of labour and led to her fears about experiencing it again.
45. The RCOG Green top guideline 52 says: ‘The midwife in charge and the first-line obstetric and anaesthetic staff should be alerted when women present with minor PPH (blood loss 500–1000 ml) without clinical shock.’
46. Mrs O’s measured blood loss was 850ml at 8.25pm and there is no evidence that staff were alerted to or aware of the situation at the time.
47. The same guidance says that measures for minor PPH include: ‘intravenous access, urgent venepuncture (taking blood) for group and screen, full blood count, coagulation screen; pulse, respiratory rate and blood pressure recording every 15 minutes, warmed crystalloid infusion (intravenous fluids).’
48. There is no evidence to suggest the midwives took any of these measures until an unknown time later before 10.15pm.
49. The Trust accepted there was a lack of escalation and a delay in treatment. It confirmed that Mrs O should have been treated earlier and that staff gave preventative doses of PPH medications instead of the treatment dose.
50. The Trust said the management of Mrs O’s care was not in line with local or national guidance and it would like to apologise sincerely for this failing.
51. The Trust also identified a number of actions:
• the importance of clear communication is raised at safety huddles and in all mandatory training • the Matron will make sure that staff are reminded at the next maternity meeting of the importance of clear communication for women and their partners • the Matron will make sure urgent training for staff takes place for the management of PPH • the difference between the prophylactic and therapeutic doses of oxytocin (PPH medication) is now clearly noted in the policy and has been discussed with all staff. There has been a focus on the management of PPH since then and there is a launch of the new PPH procedure with escalation at 500ml.
• staff are aware of the importance of accurate and contemporary documentation. The team will make sure that as well as mandatory training days, staff will be reminded about this.
52. If staff had followed the RCOG guidelines sooner, it is likely that Mrs O would have felt her concerns were being addressed and actions were taken at the right time. This may have gone some way to address Mrs O’s feelings that no one was listening to her and lessened the impact on her overall experience.
53. Our severity of injustice scale categorises a level one injustice as:
‘the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases.’
54. The impact we have seen fits with this description. The delay in escalation and management of Mrs O’s PPH was of a short duration and the wider impact was frustration. Having thought about this carefully, we do not think a financial payment is appropriate.
55. Our ‘Principles of Good Complaint Handling’ say to put things right, organisations should:
‘provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these.’
56. The Trust has given an apology and accepted its failings. It has identified a number of service improvements to make. We are satisfied the actions the Trust has agreed to take will put things right and we do not need to ask it to do more.
Incorrect time of birth
57. In its first complaint response, the Trust stated it had amended the electronic records to reflect the correct time of birth. In the records we got, this was not the case. Mrs O felt the incorrect records reminded her of her poor experience. We understand as an outcome, Mrs O wanted the records to be amended as the Trust had promised.
58. The Trust has now amended the records. This part of the complaint has now been resolved and brings this issue to a close.
59. We thank Mrs O for bringing her complaint to us and appreciate the difficult circumstances she experienced. We have spoken to her and she is happy with the outcome of this complaint.