UTI and cervical stitch
26. Mrs H says the Trust did not give her appropriate treatment for her UTI and it went on to give her a cervical stitch even though she was had a UTI.
27. We are sorry to hear about Mrs H’s concerns and understand how distressing it must be for her to think the Trust did a procedure that put her baby’s life at risk.
28. Mrs H thought she was suffering from a UTI because she was told after her appointment for the 12-week scan that there was bacteria in her urine sample. This was sent to the laboratory for investigation. But, the Trust was unable to tell if there was any sign of an infection because the sample was contaminated.
29. We understand from Mrs H’s complaint and her medical records, that she did not have any symptoms of an infection at this point.
30. Mrs H attended the Trust again to have a cervical stitch. Our understanding is Mrs H was still not showing any signs of having an infection. The Trust said a urine sample should have been taken again before the cervical stitch procedure took place.
31. The RCOG guidance says a cervical stitch is not advised if there are any signs of an infection.
32. In line with this guidance, we think it would be clinically wrong for a cervical stitch procedure to take place if the patient was showing symptoms suggestive of a UTI. But, as Mrs H was not showing UTI symptoms our adviser says it was appropriate for the procedure to go ahead. They also added that while the Trust said it should have done another urine sample before the cervical stitch procedure, this would have been precautionary and could potentially have delayed the procedure.
33. After the procedure, Mrs H began to feel unwell and went to her GP who took a urine sample. This sample was tested and results showed she had a UTI. She began taking antibiotics.
34. Mrs H went to her GP ten days after her cervical stitch procedure, with signs of a UTI. There had been time for a UTI to develop. While we cannot say this for certain, there is a possibility that there was no infection when Mrs H had the cervical stitch, but this developed in the ten days after the procedure.
35. Based on this we do not think the Trust did anything wrong by going ahead with the cervical stitch procedure when it did.
36. We considered Mrs H’s concerns that the Trust did not provide her with treatment for her UTI. The Trust did not diagnose her with a UTI and had no reason to think she had one. While we understand she was told bacteria was in her urine after the 12-week scan, when this was sent to the laboratory it was found the sample was contaminated and a diagnosis could not be made.
37. We hope our consideration helps Mrs H in understanding why the Trust continued with her cervical stitch procedure and how important it was for that procedure to go ahead.
Scan
38. Mrs H complains the Trust did a bedside scan and told her there was a heartbeat. But, during an ultrasound scan just a few hours later she was told the baby had died two weeks earlier.
39. We appreciate this was an extremely distressing time and offer our condolences for the loss of Mrs H’s baby.
40. We understand Mrs H went to A&E due to pain and bleeding. The Trust booked her in for an ultrasound scan. Before the Trust did this, it did the bedside scan. Mrs H’s records say the foetus was seen low in the uterine cavity and a heartbeat was present.
41. The Trust’s complaint response says it did a bedside scan because it was concerned Mrs H was having contractions and it wanted to see if she was dilating.
42. Mrs H’s medical records do not say why the bedside scan was done.
43. Our adviser said it is not clear why the bedside scan had been done when an ultrasound scan was booked in for later that day. They also said a bedside scanner is much smaller than an ultrasound scanner and does not pick up as much detail.
44. The Trust’s response says Mrs H was 14 weeks pregnant and the baby’s head circumference measured around 12 weeks. The Trust goes on to say this could either mean the baby’s heartbeat stopped at 12 weeks or after her 12-week scan, the baby did not continue to grow as expected and died at 14 weeks when only measuring the size of a 12-week baby.
45. Based on a review of Mrs H’s medical records we think that Mrs H was around 14 weeks pregnant. The measurement the Trust used was taken from the bedside scan. Our adviser said as the baby’s head was low in the uterine cavity this can lead to some difficulties in taking accurate measurements and may be the cause of the slightly unexpected date calculation.
46. Our adviser agrees with the Trust’s explanation that either the baby’s heartbeat could have stopped at 12 weeks, or the baby continued to have a heartbeat but did not grow as expected from 12 weeks. They added that due to the nature of the bedside scans and where the baby was positioned, the Trust could have thought there was a heartbeat when there was not. This is because of the type of scanner and where the baby was positioned it is difficult to detect a heartbeat with any certainty. The adviser was unable to say which scenario would have been more likely.
47. We will never be able to say whether Mrs H’s baby’s heartbeat stopped at some point after the 12-scan and was mistakenly picked up on the bedside scan, or if the heartbeat seen in the bedside scan was correct and it stopped shortly after but before the full ultrasound scan.
48. There is also no guidance relevant to this that would help us to distinguish whether the baby had died before the bedside scan or in the time between the bedside scan and ultrasound scan.
49. We understand this caused Mrs H distress and upset. We also understand Mrs H may be frustrated that we are unable to explain exactly what happened.
50. Within the Trust’s response letter it said there could have been an error with the bedside scan or it might have been that Mrs H’s baby had died after the bedside scan but before her ultrasound scan.
51. The Trust has also apologised because this was not clearly communicated with Mrs H at the time. It sent a copy of Mrs H’s complaint to the team for learning and reflection. The Trust also discussed the findings of its investigation with its sonographers (who do the scans), so they understand the importance of communication and choice of words.
52. We consider this to be in line with our NHS Complaint Standards that say we expect organisations to promote a learning culture and be open and accountable when things go wrong. As the Trust has accepted it did not handle Mrs H’s situation with sensitivity and did not communicate with her appropriately and has apologised, we do not think there is more for the Trust to do to put things right.
53. We are sorry to hear of the traumatic experience Mrs H had. We understand our consideration will be very hard for Mrs H to read. We hope she is reassured that the Trust has taken learning from this situation so it does not happen again. While we will never be able to say with certainty when Mrs H’s baby died, we hope she is reassured the communication from the Trust in these circumstances will be better since she made her complaint.
Cervical stitch
54. Mrs H says when she was miscarrying her baby, the Trust did not have the right equipment available to remove her cervical stitch.
55. We are again sorry to hear about Mrs H’s concerns in what was an already traumatic time for her.
56. We understand from Mrs H’s medical records that her stitch was cut after confirmation of her miscarriage, but, some of the stitch stayed in place. This was removed after the delivery of the baby and the placenta. We understand this was due to the position Mrs H was in when the Trust first attempted to remove the stitch. The medical records suggest it was easier for the Trust to remove the stitch in the treatment room than on the ward.
57. The NMC’s guidance says nurses and midwives should treat people as individuals and keep their dignity. It goes on to say this should be achieved by ‘treating people with kindness, respect and compassion.’
58. We think the Trust acted in line with this guidance by agreeing to fully remove Mrs H’s cervical stitch when she was in a treatment room and in a different position.
59. We do not think there was any problem with the equipment available to cut Mrs H’s cervical stitch. There is also no sign of any issues with the equipment available at the time it removed her cervical stitch.
60. We understand this was a terribly tragic situation for Mrs H and it was not helped by the Trust having to attempt to remove her cervical stitch on two different occasions. We hope our findings reassure Mrs H this was not because the Trust did anything wrong. We think the Trust acted correctly by waiting until Mrs H was in a different room and in a different position to remove the cervical stitch, rather than attempt to move her at the time.
Cutting the umbilical cord
61. Mrs H says when she was miscarrying her baby, the Trust did not have the appropriate equipment available to cut the umbilical cord.
62. Mrs H’s medical records show that after her ultrasound scan confirmed there was no heartbeat, the Trust waited to see if Mrs H would miscarry naturally. At 1.30pm on the same day, the Trust cut Mrs H’s cervical stitch. By that afternoon there were no signs of spontaneous delivery. So, at 4.50pm, medical management of Mrs H’s miscarriage (medication is given to help the uterus pass any pregnancy tissue) was started. Our adviser said this was appropriate given the pain Mrs H was experiencing.
63. Mrs H says because of the Trust’s failing to cut her baby’s umbilical cord she was left with the baby attached to her until the Trust could find equipment to cut the umbilical cord.
64. The Trust said on the ward Mrs H was being cared for they treat many patients with different admission reasons and not all equipment is kept in every room as standard.
65. We have been unable to find any evidence within Mrs H’s medical records that there was an issue with the equipment needed during the procedure. But, we do not think this means it did not happen. This is because the Trust has also confirmed that not all equipment is in every room as standard.
66. There is no guidance to suggest what equipment should be available to staff when a patient is going through a miscarriage.
67. Mrs H remembers no equipment being available to cut the umbilical cord so the member of staff had to cut it with what equipment they could find.
68. Mrs H added she gave birth to her baby on the toilet, so she had to wait in the toilet until the nurse was able to cut the umbilical cord. She says it took around five to seven minutes for this to happen and then the nurse took the baby way.
69. The NMC’s guidance says nurses and midwives should treat people as individuals and uphold their dignity. It says this should be achieved by ‘treating people with kindness, respect and compassion.’
70. We think the Trust kept to this guidance as it quickly resolved the issue to reduce the impact on Mrs H.
71. We understand this was an extremely traumatic time for Mrs H and we understand that while this delay lasted only minutes, Mrs H found it awfully distressing and upsetting. We thank her for sharing details of such a sad and sensitive time with us. We appreciate our thinking on this part of her complaint may be difficult for her to read.
72. There is no guidance to say what should be in a treatment room at any time and we think the Trust tried to fix this issue as quickly as possible. This means we cannot say Mrs H’s experience fell so far below our service expectations to be a failing.
Ward
73. Mrs H says when she returned to the Trust in August 2022, she was put on a ward with other pregnant woman and across from the room where she miscarried only a week before.
74. We understand this would have been a distressing situation for Mrs H to be in.
75. Mrs H’s medical records confirm she was put on a ward with pregnant women and was in a bed opposite the room where she was told she had a miscarriage. We understand when Mrs H raised her concerns about this at the time, the nurse in charge apologised to her and offered her a different room.
76. The Trust’s guidance says anyone who is under 20 weeks pregnant and needs to be admitted to hospital will be admitted to ward [X].
77. The Trust said this ward is not a maternity ward but will have other patients who are also under 20 weeks pregnant and need to be admitted to hospital. The Trust also says if a patient is admitted to this ward with a miscarriage, it ideally tries to care for them within one of the two bereavement rooms. But, if these rooms are full another room will need to be used.
78. We think this is what happened with Mrs H. We can see the Trust were quick to offer her another room when she told staff about the problem.
79. We understand how distressing and upsetting it would have been for Mrs H to see other pregnant women and to be put in a room opposite where she had a miscarriage. We have not seen the Trust has done anything wrong. Unfortunately, in cases like these there are limited beds on a ward and we think the Trust acted appropriately by offering to move her when it realised she was distressed.
Blood test results
80. Mrs H says the Trust sent her someone else’s blood test results. We appreciate this was worrying and confusing.
81. Mrs H says she knew there was a problem because the blood group referred to in the letter was different to hers. Mrs H contacted the Trust by phone and was told the results she had been sent were wrong.
82. This is a failing because the incorrect results were sent to Mrs H. We go on to look at the impact this had on Mrs H.
83. Mrs H said her whole experience has led her to lose faith in the Trust and it added distress to an already very distressing situation.
84. In the Trust’s response it says when it became aware of this issue it contacted Mrs H to discuss the issue and apologised.
85. The distress caused by being sent the wrong blood test results would have lasted for the time it took Mrs H to realise the mistake to when she contacted the Trust. We understand Mrs H contacted the Trust as soon as she realised the problem so the distress lasted for a very short time.
86. Our guidance on financial remedy include a severity of injustice scale. This has six different levels of injustice that a complaint could fall into and these increase in severity. Each level is then linked to a range of financial payments that we would usually recommend in those circumstances. This scale is available on our website and allows us to be consistent and transparent when we are making recommendations.
87. We believe the impact this has had on Mrs H would fit into level one. A level one impact is described as when someone has ‘experienced a low impact injustice such as annoyance, frustration, worry or inconvenience. This would typically arise 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.’ For these cases we think an apology is enough.
88. The Trust has already acknowledged and apologised for its failing and the impact it had on Mrs H. We do not think the Trust needs to do anything more.
89. We understand Mrs H was already going through a very distressing time after losing her baby and we understand being sent the wrong blood test results would have caused more upset. We hope she understands our consideration and is reassured that we think the Trust has done enough to put this right.