Issue 1 – Sign posting to housing support
15. The Trust’s Antenatal Care Policy (2018) says all women should be encouraged to see their community midwife throughout the pregnancy to ensure all areas of need are addressed including social, and psychological.
16. Derby City Council Early Help Handbook should be used by all health and social care professionals in Derby city working with families which display emerging needs that require contact with early help services. The Trust is expected to use the Early Help Assessment framework to request support, and identify low level and emerging needs, such as housing support. A midwife may consider an Early Help Assessment in cases where a pregnant woman had raised a specific issue that would call for a referral or the midwife had concerns for the safety of either the mother or the baby.
17. Mrs R says at her 28-week appointment Midwife 3 (standing in for her usual midwife, Midwife 1) mentioned the Early Help Assessment but did not give her enough information to know what this was about. The antenatal booking summary records ‘N/A for the Early Help Assessment’. This suggests the midwife discussed this with Mrs R but did not record any concerns.
18. Our midwife adviser told us there is no specific guidance, process or requirement that prompts a midwife to ask about housing needs. Mrs R says she told midwives, she was having problems with their landlord, and could not use the cooker. There is no conversation recorded in the antenatal notes of Mrs R raising housing concerns. Unfortunately, there is not enough information available for us to know what Mrs R discussed with midwives about her housing needs.
19. Mrs R has given us her account of raising concerns about her landlord and oven, and we can see the midwife considered the Early Help Assessment, and did not feel it was necessary to refer Mrs R. There is no other information in the records to know what was discussed.
20. The midwife could have recorded more detail in the notes to explain why she considered the referral was ‘n/a’. We consider this to be a shortcoming. There is no requirement for midwives to ask about a woman’s housing needs and on the balance of evidence available, we cannot say the Trust were aware of any concerns that would have meant they should have made an Early Help Assessment referral in line with Derby City Council Early Help Handbook. While there were shortcomings in the lack of detail recorded in the notes, we cannot say this fell so short of the standards, as to be a failing. We recognise this decision will be disappointing for Mrs R because she has told us the distress, anxiety her family experienced because of the lack of support they received for their housing needs.
Issue 2 – Birth planning
21. The Trust told us it did not have guidelines about birth plans at the time of the events. The Trust Antenatal Care Policy (2018) says ‘women should be the focus of maternity care, with an emphasis on providing choice, easy access and continuity of care. Care during pregnancy should enable a woman to make informed decisions, based on her needs, having discussed matters fully with the health professionals involved’.
22. There is no requirement for midwives to support women to make a birth plan. However, NICE guideline on Intrapartum care for healthy women and babies says: • midwives should explain to women they may choose any birth setting • if the woman has written a birth plan, read and discuss it with her • explain sensitively any findings of vaginal examinations and any impact on the birth plan • treat all women in labour with respect. Ensure that the woman is in control of and involved in what is happening to her and recognise the way in which care is given is key to this. To facilitate this, establish a rapport with the woman, ask her about her wants and expectations for labour • healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion, and that appropriate informed consent is sought.
23. Royal College of Gynaecologists (RCOG) guidelines on obtaining consent says care must be taken when obtaining consent from women who are in labour, particularly if they are in pain or under the influence of narcotic analgesics. And where possible, women should be informed during the antenatal period about predictable problems that may occur during labour.
24. Mrs R says the Trust never told her about her birth rights, or options. She said midwife 2 stood in for midwife 1 at one appointment and told her to discuss the birth plan with midwife 1. She says midwife 1 told her not to bother with a birth plan and did not fill out the birth plan section in her handheld maternity notes.
25. The RCOG guidelines explains that that as care is needed getting consent from women in labour. This is because they may be exhausted, in pain, and affected by opiates which can all affect their judgement to give meaningful informed consent. The RCOG guidelines explain that staff should give information to women about all possible birth scenarios such as an instrumental delivery in advance of labour. There is nothing in the records that suggests the hospital gave Mrs R information in advance about the possible need for an instrumental delivery with forceps in line with the RCOG guidance.
26. While there is no requirement for midwives to support women to make a birth plan, we would expect to see documented discussions about what could happen during birth. There is no mention of a birth plan, or record of any discussion about birth options, in the records. We have not seen evidence in the notes of midwives giving Mrs R any information about how to make an informed choice about her birth, or possible outcomes such as a forceps delivery. This is not in line with the Trust’s antenatal care policy, NICE guidance on Intrapartum care and RCOG guidance on obtaining consent. Our view is this was a failing.
27. We will consider the impact of this in paragraphs REF _Ref160005617 \r \h \* MERGEFORMAT 76 to REF _Ref170225945 \r \h \* MERGEFORMAT 88.
Issue 3 – Consent and communication during labour
Moving to the labour room:
28. NICE guideline on Intrapartum care for healthy women and babies says: • healthcare professionals should ensure in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so the woman is in control, listened to and cared for with compassion, and appropriate informed consent is sought • in the case of any medical conditions, or factors that may affect planned place of birth, discuss these risks and the additional care that can be provided in the obstetric unit with the woman so they can make an informed choice about planned place of birth.
29. The NMC Code of Practice says Midwives should communicate clearly and check people’s understanding.
30. Mrs R was admitted to the birth centre on 6 July 2019 at 11.55pm. Her waters had broken, and she was in advance labour and had high blood pressure. This moved her from low to high risk and the Trust transferred her to the labour ward.
31. We recognise how distressed Mrs R was because she told us she did not know what was happening as no one told her she was moving to a room on the labour ward. Mr R says the two midwives talked amongst themselves about the room change but did not explain this to either of them. Mr and Mrs R recall midwives told them they were taking Mrs R for a walk to progress labour and moved her with only a bedsheet covering her naked body. Mr R says he asked what was happening and the midwife replied, ‘we are moving her to another room’.
32. The records say at 1.23am on 7 July, following a vaginal examination assessing the decent of the baby’s head midwives ‘advised to transfer to room on labour ward’. This suggests the Trust discussed moving to the labour room with Mrs R as they should have in line with NICE guidance on Intrapartum Care.
33. We acknowledge Mr and Mrs R’s account is different to what is written in the records. Mr R says he heard midwives talking amongst themselves about the room change. This suggests there was at least some discussion happening in the room, even if this wasn’t directed to Mr and Mrs R.
34. In line with the NMC code of conduct, midwives should have communicated directly with and included them in the discussions. There is no record of what they discussed, so there is not enough evidence available for us to know what was said or to what extent midwives were involving Mr and Mrs R in that discussion. Based on the evidence available, we cannot say what happened here. However, when we consider this in the wider context of Mrs R’s experience of how the Trust communicated with her during labour, we have found some failings in the way staff communicated with her overall, and we know she did not feel listened to.
Consent for the forceps and episiotomy procedures:
35. RCOG’s guidance (2015) on obtaining valid consent says prior to emergency procedures there is scope to allow verbal consent when it is considered to be in the mother or baby’s best interest.
36. The Trust policy on Operative Vaginal Delivery (an instrumental delivery with forceps or a vacuum) says: • to gain consent ‘each operator must ensure they have verbal consent from the patient and document this clearly in the notes. This should include an explanation of what the procedure will entail, why the procedure is being undertaken and the likelihood of an episiotomy’.
• consent needs to be obtained by discussion not only of these risks (of forceps delivery) but additionally the risk of caesarean section.
• an indication for operative vaginal delivery is inadequate progress in the second stage.
37. As explained above, NICE guidance on Intrapartum care says there should be a culture of respect for each woman and appropriate informed consent should be sought. It also says if the birth needs to be expedited, assess both the risk to the baby and the safety of the woman. Assessments should include: • the degree of urgency • choice of mode of birth (and whether to use forceps) • the woman’s preferences.
It says talk with the woman and her birth companions about why the birth needs to be expediated and what the options are.
38. The records say at 2.30am a midwife recorded she discussed with Mrs R the doctors plan for further medical review if there was no change in the next 15 minutes. At 2.40am Mrs R had a vaginal examination and the plan was for a doctor to review her due to the prolonged second stage of labour. The plan following the doctors review was for another hour of pushing and following this for Mrs R to have an instrumental delivery (via forceps) as both mother and baby were tired and the baby’s heart rate was showing some decelerations. Mrs R has recollection of this as she recalls a doctor told them if the baby had not been born by 4am the Trust would do an instrumental delivery.
39. The hospital records say at 4.15am staff asked Mrs R if she wanted to go to theatre or stay in the room, and she asked to stay in the room to have her baby. This accords with Mrs R’s recollection, and she says she did not understand what the doctor meant.
40. Our obstetrician told us the context of this is when doctors examine the patient and decide if a forceps delivery is needed, they need to make a clinical judgment about whether they can safely deliver the baby in the labour room. If they anticipate a delivery with forceps may be difficult or not possible, they will attempt a forceps delivery in theatre, so staff are prepared to do an emergency caesarean section if the forceps delivery is unsuccessful.
41. They added it would not be appropriate for a doctor to ask the patient which area they would prefer to deliver in, because this is a clinical decision based on clinical assessment, safety and risks. The doctor should make a clinical decision and communicate this with the mother advising which site of delivery would be best and explaining the rationale. We consider the choice doctors gave Mrs R to go to theatre or stay in the room was not effective communication. This would have understandably caused Mrs R confusion particularly as she was in active labour (the pushing stage) and the records indicate she was tired.
42. Mrs R says the Trust should have asked her permission to do a forceps delivery, instead of telling her what would happen. She says the Trust didn’t explain why it needed to do this, or the risks involved. She says staff did not tell her they would do an episiotomy and she did not consent. Trust staff’s recollection of communicating about the chances of needing to do an episiotomy differs from Mrs R’s. The Trust said Midwife 2 recalled Doctor 1 explaining an episiotomy may be necessary to assist with the forceps.
43. Doctors should set out information in the notes about what the woman had specifically consented to. The Trust said staff recorded verbal and written consent, we have not seen evidence of written consent in the records. The doctor ticked the instrumental delivery sheet to indicate verbal consent. This is in line with RCOG’s guidance which allows verbal consent. However, the records do not include any information about what kind of discussion took place, whether the discussion was adequate, or what specifically Mrs R was consenting to.
44. It does not specify that Mrs R was consenting to the forceps delivery including an episiotomy. The proforma instrumental delivery sheet does not enable or include space for free text for the information required (by the Trust’s policy on Instrumental delivery) to be recorded. The tick box is inadequate documentation of consent.
45. We cannot tell from the records if the consent discussions the doctor had with Mrs R were adequate. Our view is the lack of documentation to evidence an appropriate discussion about consent is a failing.
Male Doctor:
46. Mrs R says the Trust did not consider her Roman Catholic values and she did not want a male doctor present.
47. GMC Good Medical Practice says doctors must take account of patient’s views. If during pregnancy a mother says she wants a female doctor, the Trust should try to respect that or explain the reasons they cannot. However, there is no statutory requirement for the NHS to provide a clinician of the same sex in any healthcare setting. The NHS’s ability to respond to such a request will be considered on an individual basis and will be dependent on such circumstances as levels of staffing and the needs of other patients.
48. We have not seen records in the notes saying Mrs R requested a female only doctor during pregnancy or labour. If a mother waits until labour to request a female doctor, it may be very difficult to find a female doctor with the required level of experience. It’s not always possible during labour to provide a female doctor.
49. Mrs R had a delayed second stage of labour, and it became necessary for an obstetrician to support Mrs R to have an instrumental delivery using forceps. This is in line with the Trust’s guidance on calling paediatricians for delivery. At this time the female doctor was attending another emergency, so staff called Doctor 1 to attend. The Trust said it makes every effort to accommodate a female doctor. However, it is not always possible to achieve this. While this was not an emergency delivery, there still may not have been a senior enough female doctor available to help with delivery at that time.
50. We do not uphold this part of the complaint because we have seen no evidence Mrs R requested a female doctor, so we cannot say the Trust failed to take account of her views as it should have in line with GMC Good Medical Practice. Even if Mrs R had requested a female doctor, we accept it may not have been possible for the Trust to provide a female doctor. Its ability to accommodate this request was based on the clinical demands on the ward at that point, and the Trust told us the female doctor was busy at that time. We do recognise Mrs R was upset a male doctor delivered her baby, because of her Roman Catholic values.
Taking communication into account:
51. GMC Good Medical Practice says doctors must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
52. NMC code of practice says nurses must take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs. If a patient requests assistance with communication midwives would be expected to support this and communicate in line with the woman’s needs.
53. Mrs R told us she has a hearing impairment. She said staff didn’t take account she couldn’t hear in her right ear.
54. The midwife adviser told us midwives recorded at the 12 weeks booking appointment Mrs R had sensorineural deafness. The notes say she is deaf in one ear, and a BSL interpreter was not needed. The labour ward risk assessment tool says Mrs R was partially deaf. There is nothing else recorded to say whether/what requirements or adjustments were needed in the records. If Mrs R had asked for assistance at her antenatal appointments, the Trust would have had time to plan and provide additional support. However, we have not seen evidence she asked for support.
55. There is nothing documented in the labour records saying staff had considered Mrs R’s deafness while she was in labour. The midwife adviser said if a woman was deaf in one ear, and struggling to hear, the patient would be responsible to tell staff they couldn’t hear and ask for support. There is no record in the antenatal notes of Mrs R asked for assistance with her communication.
56. We have seen the Trust noted Mrs R’s hearing impairment at the 12 weeks booking appointment, and at that time recorded that a BSL interpreter was not required. Without evidence of Mrs R asking for assistance with her communication, there is no requirement for staff to have met these needs in line with NMC code of practice. Therefore, we do not uphold this part of the complaint. We are sorry to learn about the difficulties Mrs R encountered when she could not hear her midwife.
Summary of consent and communication during labour
57. We have found some failings in the way staff communicated with Mrs R overall and we know she did not feel listened to. We cannot tell from the records if the consent discussions the doctor had with Mrs R were adequate. We do not know to what extent midwives were involving Mr and Mrs R in discussions about her care or room changes. Our view is the lack of documentation to evidence appropriate discussion about consent is a failing. We will discuss the impact of this in paragraphs REF _Ref160005617 \r \h \* MERGEFORMAT 76 to REF _Ref170225945 \r \h \* MERGEFORMAT 88.
Issue 4 - staff did not take account of her anxiety
58. NMC code of practice says midwives: • should treat people with kindness, respect and compassion and should make sure people’s physical, social and psychological needs are assessed and responded to.
• make a timely referral to another practitioner when any action, care or treatment is required.
59. NICE guidelines on Intrapartum care says midwives should ask how the woman is feeling and whether there is anything in particular she is worried about.
60. NICE guidelines on Antenatal care says: • at the booking appointment midwives should discuss mental health issues and ask about any past or present severe mental illness.
• before or at 36 weeks a midwife should discuss awareness of ‘baby blues’ and postnatal depression.
61. The Trust antenatal booklet includes a mental health and wellbeing survey which should be completed at the booking and 26 and 30-week antenatal appointments. The antenatal booklet says the aim of this survey is to ‘prevent or reduce mental ill health in women. The following questions will help us discuss with you any support you may need or after your pregnancy. Your midwife will discuss these questions with you’.
62. NICE guidance on antenatal and postnatal mental health says Trusts should have a specialist perinatal mental health service in each locality to provide direct services, consultation and advice to maternity services.
63. Our midwife adviser told us if a woman told midwives she was experiencing overwhelming anxiety, midwives should record this in the notes and discuss and consider additional support such as a referral to the Perinatal Mental Health Team
64. Maternal journal is a creative, psychosocial and therapeutic tool developed by Kings College London to help women at increased risk of mental health problems before and after childbirth.
65. Our midwife adviser told us it is usual for maternity units to offer a ‘birth afterthoughts’ service where the Trust offers the mother an opportunity for a debrief to discuss their birth with a midwife. This is good practice in line with an article on ‘Birth Afterthought: a listening and information service’. Our midwife adviser told us, if after a debrief, the mother needs further support the Trust can refer them for more support with a specialist midwife or with their GP.
66. First, we will consider the support midwives gave Mrs R during her pregnancy. The records show the midwife discussed Mrs R’s history of anxiety at the booking appointment, in line with NICE guidance on antenatal care. The records do not say if Mrs R asked for any adjustments, additional support or if the midwife considered this.
67. The records say midwives asked about Mrs R’s mood at 34 weeks and documented this as ‘good’. There is no other mention of anxiety in the antenatal records. There is no other record of midwives asking Mrs R about her mood or completing the mental health and wellbeing forms at the 26 and 30 week antenatal appointments, as they should have in line with the Trust’s policy on completing the Mental Health and Wellbeing Survey. Our view is this was a failing.
68. Now we will consider the support midwives gave Mrs R during delivery and on the postnatal ward for her anxiety. Mrs R says she told the midwives at delivery about her anxiety. She said no one supported her to talk about the distressing birth. A nursing checklist recorded Mrs R as being anxious.
69. The post-natal records on 10 July (3 days after birth) the midwife recorded Mrs R’s blood pressure was slightly raised and she appeared anxious. The midwife encouraged Mrs R to take some deep breaths and her blood pressure returned to normal limits. Mrs R was discharged home at 8.30pm. The doctors review before discharge says Mrs R was anxious about her 2-year history of vertigo. The records show staff recognised Mrs R was anxious, but there is not enough information to know to know what staff discussed with Mrs R about her anxiety and whether they gave appropriate reassurance and support.
70. Now we will consider the post-natal support midwives gave Mrs R for her anxiety after she had been discharged from hospital. On 11 July (4 days after birth) at a home visit, the midwife recorded that Mrs R was anxious and said she found the birth traumatic and wanted to make a complaint. In line with this, the midwife gave Mrs R PALS contact details.
71. At a postnatal clinic the same day, Mrs R expressed her anxiety to the midwife. The midwife advised Mrs R to keep a maternal journal which was good practice in line with the Maternal Journal project set up by Kings College London. The midwife wrote that she would refer Mrs R to the specialist peri-natal mental health midwife, but we have not seen evidence the midwife made the referral.
72. Mrs R expressed her anxiety and said she was feeling ‘up and down’ at a postnatal clinic on 18 July (11 days after birth). The midwife advised her to see her GP. Mrs R said she wasn’t too bad and would self-refer to GP if needed. The notes say staff would refer Mrs R for a debrief at the Trust (this was in line with the practice of maternity units offering ‘birth afterthoughts’).
73. Following this, a midwife contacted Mrs R about her concerns and her complaint on 22 July. The midwife reassured Mrs R the Trust would thoroughly investigate her complaint. The Trust complaint response says midwives wanted to arrange a debrief meeting. However, Mrs R said she wanted to pursue answers through the complaint route. The Trust offered a further debrief meeting in January 2020, but Mrs R declined this. The Trust said if she changed her mind, this could still be arranged. We have seen the Trust offered Mrs R the opportunity to discuss her anxiety about her birth at a debrief. As Mrs R declined this opportunity, our view is not to uphold a complaint about the Trust’s failure to support Mrs R to talk about her traumatic birth.
74. There appears to be a gap between what should have happened and what did happen with regard to the Perinatal Mental Health Team referral. Midwives identified Mrs R’s mental health concerns four days after birth and recorded they would make the referral. The midwives should have referred Mrs R to the Perinatal Mental Health Team when Mrs R expressed her anxiety four days after birth. This would have been in line with the NMC code of practice to make a timely referral to another practitioner.
75. We have not seen any evidence they did this, and the records suggest midwives had still not completed this referral 11 days after birth because the notes suggest the Trust had still had not arranged a debrief. We have also seen evidence the GP sent a referral to Perinatal Mental Health Team 6 weeks after the birth of Mrs R’s baby, which suggests midwives had not done this.
76. Our view is the Trust failed to complete the mental health and wellbeing forms at the 26 and 30-week antenatal appointments in line with the procedure set out in the antenatal booklet. We consider it also failed to refer Mrs R to the Perinatal Mental Health team in line with the NMC code of practice.
Impact
77. Our view is the Trust failed to: • give Mrs R any information about how to make an informed choice about her birth or possible outcomes such as a forceps birth, as it should have in line with the Trust’s antenatal care policy, NICE guidance on Intrapartum care and RCOG guidance on obtaining consent • document appropriate discussions about consent for the forceps birth and episiotomy • complete the mental health and wellbeing forms at the 26 and 30-week antenatal appointments in line with its policy • refer Mrs R to the peri-natal mental health team in line with the NMC code of practice.
78. Mrs R says because midwives did not give her information during her pregnancy about how to make informed choices about her birth, she did not know what her rights were, or what options were available. Because of this she found her birth traumatic. We can see Mrs R was scared during the episiotomy and did not understand what the doctor was doing at the time. She found the procedure painful and questions why the midwives were holding her legs. Mrs R says she felt assaulted.
79. We acknowledge Mr R has told us their complaint has had a profound impact on him and caused him distress. He also told us how he continues to act as a support system for Mrs R because of the ongoing impact the trauma has had on her.
80. We accept that an impact of the Trust not giving Mrs R enough information (about what could happen during labour) in advance, and not documenting consent discussions, could have contributed to the birth trauma she told us she experienced, and the distress Mr and Mrs R said they both felt. If the Trust had better explained what might happen, and what Mrs R’s rights and options were at each stage, Mr and Mrs R might have been better prepared for what was happening. This might have lessened the trauma and distress they experienced.
81. We cannot say that, even with this information, Mrs R would not have found the birth traumatic as a forceps delivery with an episiotomy is a very uncomfortable procedure. But we consider the Trust missed opportunities to give Mr and Mrs R information which may have reassured them and lessened the trauma and distress they experienced.
82. The Birth Trauma Association says about 4-5% of women experience PTSD after birth, and many more experience trauma symptoms. It says a difficult forceps birth can make birth traumatic. Often women say the trauma of the birth has been made worse by poor communication from the health professionals looking after them.
83. We accept Mrs R says her traumatic birth experience contributed to her distress and anxiety. We have seen health visitors shared concerns about Mrs R’s mental health with the GP. A GP letter dated August 2019 listed her pre-existing conditions of anxiety and depression and stated, ‘she had a traumatic delivery and is currently going through a bit of traumatic stress disorder’.
84. The GP made a referral to the Perinatal Mental Health Team because they felt Mrs R was ‘high risk for post-natal depression’. We cannot say to what extent the failings we identified impacted on Mrs R’s mental health. This is because she had preexisting conditions of depression and anxiety which, on balance, would have increased during childbirth. However, we can say that failure to support Mrs R to make informed choices increased the anxiety she felt.
85. We consider that failure by the Trust complete the mental health and wellbeing forms or refer Mrs R to the peri-natal mental health team after birth were missed opportunities to consider and provide support for Mrs R’s mental health.
86. We do not know if Mrs R would have accepted support from the Perinatal Mental Health. This is because when she was referred by the GP to the Perinatal Mental Health Team (on 14 August 2019) Mrs R chose not to attend. Mrs R has told us that this was because she was fearful the health visitors were trying to make false safeguarding allegations about her. It is possible that earlier engagement with the Perinatal Mental Health Team may have provided greater reassurance. This may have helped Mrs R to feel more supported at a time of increased anxiety.
87. Although we cannot know what may have happened had the support been provided earlier, we can see that this caused additional stress (on top of what she felt usually) as a consequence of the failings.
88. Using on our severity of injustice scale, the distress Mrs R experienced likely sits at level 3. This is because she experienced a ‘single traumatic or highly distressing experience where there was no other significant adverse impact’.
89. We can see that Mrs R says she has experienced significant ongoing trauma. We consider the failings we identified partly contributed to this distress and anxiety. We cannot say the failings wholly caused her distress because Mrs R already had underlying depression and anxiety and even if the failings we have identified had not occurred, Mrs R would still likely have found her birth traumatic. However, there were missed opportunities for the Trust to communicate with Mrs R and consider her mental health needs. This may have lessened the trauma she experienced.
Is the injustice unremedied: 90. We have seen an internal Trust ‘complaint management review’ partly upheld the complaint and said communication could have been improved about the episiotomy. As part of this review, it accepted and apologised that Mrs R did not feel adequately supported to make a birth plan. The Trust have also apologised that the communication during Mrs R’s pregnancy, labour and birth did not meet the standards it aimed for. It has acknowledged that at times communication was not clear and it could have clarified and explained certain matters, issues, processes and procedures better, to offer further reassurance. It has also apologised to Mrs R as she felt unsupported by midwives regarding her anxiety.
91. The Trust identified areas of improvement. It told us it now includes guidance on birth plans in its antenatal care and labour care guidelines. The Trust’s new antenatal care guidelines say the Trust should provide information about creating a birth plan at the 28 weeks antenatal appointment. Its labour care and risk assessment policy says staff should discuss the woman’s birth plan when women are in suspected labour.
92. The Trust have taken actions to feedback to maternity teams about: • the importance of clear communication and Trust values around care and treating people in a supportive manner • communicating appropriate information about home birth options • Mrs R’s feedback about being transferred from room to room with only a sheet wrapped around her and maintaining privacy and dignity at all times.
93. We have seen as part of NMC’s response: • midwife 1 (present at antenatal appointments) reflected she did not recognise how anxious Mrs R was. She says she did her best to answer questions and reassure Mrs R, but on reflection this intention was not achieved on her part. She said she could have explored Mrs R’s mental health in more detail and made more enquires about present mood and emotional wellbeing. She said she now makes enquiries about this at every contact.
• midwife 2 reflected she will ensure good communication between all staff and the patient and their family. She acknowledged its important the family know what is happening and why. She will ensure contemporaneous documentation is maintained and record all direct care, observations and communication.
94. We acknowledge the Trust has taken steps to remedy Mrs R’s complaint that it did not support her to write a birth plan or communicate fully about what was happening. We have seen the Trust apologised to Mr and Mrs R about these. We do not consider an apology on its own to be a proportionate remedy to the injustice Mrs R experienced, in line with our principles for remedy.
95. We have not seen evidence the Trust has taken steps to ensure staff complete the mental health and wellbeing forms at the 26 and 30-week antenatal appointments or appropriately consider referrals to the peri-natal mental health team in line with its policy and the NMC code of practice.
96. For these reasons, whilst we welcome the actions already taken by the Trust, we consider these do not go far enough to put things right for Mrs R, and we partly uphold the complaint.