Baby’s heartrate on admission and not escalating concerns
17. Before we decide if we should conduct a detailed investigation of 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 in Miss L’s care and have not found any indications that something has gone seriously wrong. We understand this was a distressing time for Miss L and explain the reasons for our decision, below.
18. Miss L complains that staff did not inform a consultant when her baby’s heartrate decelerated on her admission to the Trust. In its complaint response the Trust said the registrar reviewed Miss L and stated the decelerations may be due to cord stimulation with movements, or maternal cough. It said it was unlikely due to fetal compromise, as the CTG was back to normal. Staff did not feel it necessary to contact the consultant as Miss L was stable.
19. We reviewed this issue with help from our adviser.
20. GMC guidelines explain that if doctors assess, diagnose or treat patients, they must take account of their history, and where necessary examine the patient. They should also promptly provide or arrange suitable advice, investigations or treatment where necessary.
21. In Miss L’s care, the interpretation of the CTG required an evaluation of the IUGR and prematurity of the baby.
22. The evidence indicates the registrar was a specialist doctor which means they were senior and experienced, and not required to discuss clinical situations with a consultant.
23. The CTG performed on 24 January showed good baseline variability (variation of fetal heart rate from one beat to the next) which is an indicator of a good central nervous system perfusion (the flow of blood or fluid to tissues and organs). Our adviser explained that these results are appropriate for a 30-week pregnancy.
24. We can see there were one to two short decelerations in the CTG. These are not uncommon in a CTG at 30 weeks’ gestation and are due to brief umbilical cord compression (when the umbilical cord can become compressed when the baby's weight, the vaginal walls, or the placenta strain the cord) and the decelerations are not a sign of shortage of oxygen.
25. We think the doctor who reviewed Miss L interpreted the CTG correctly, the decelerations seen in Miss L’s baby’s heartrate did not require any action (for the reasons above) and they did not need to escalate this to a consultant. We think Miss L’s management was appropriate and this is in line with the GMC guidelines highlighted under this issue.
Transfer to a different hospital
26. Miss L told us she was not given an option to transfer to a different hospital on the morning of 26 January, and she was told she was not a priority.
27. In its complaint response, the Trust said if Miss L’s condition deteriorated or she was concerned about fetal movements, she would be transferred to the tertiary unit (specialised care in a hospital setting). It said in view of the fact she was happy with the fetal movements, and the CTG was normal, the decision was made for her to stay. We recognise Miss L’s recollection of this conversation differs to that of the Trust and acknowledge the worry she felt at that time.
28. As highlighted under issue one, GMC guidelines explain that when doctors assess, diagnose or treat patients, they must take account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values and where necessary, examine the patient.
29. Transfer to another unit many miles away with no clear idea about when delivery will occur, can be disruptive to the patient and their family and can have a significant negative impact on social support and mental health. So, it is important to ensure that timing is appropriate although this is often not easy.
30. If transfer has not taken place, and immediate delivery is required, local paediatricians (doctors who diagnose and treat conditions that affect babies and children) can usually stabilise the baby and then transfer the baby out to an appropriate unit.
31. RCOG guidelines explain the delivery of a baby would not normally be undertaken under 32 weeks’ gestation, when there is end-diastolic flow (blood flow at the end of the heartbeat) in the umbilical artery, unless other concerns were present. Another marker of the baby’s wellbeing is the baby’s movement.
32. The evidence we have seen, indicates a conversation was held with Miss L about transfer to a different hospital and the obstetrician (a doctor who specialises in care during pregnancy, labour and after birth) who reviewed her, took advice from the paediatric team. The team advised they would like to transfer Miss L if there were any concerns with the baby’s movements, concerns with the CTG or if she experienced any pain.
33. We note the medical records do not specifically detail that Miss L was given the option of transfer, but that she was given an explanation and following this, she decided to stay until the next day. In its serious incident report, the Trust provided the obstetrician’s statement and according to this, they did give the option of transfer to her, and she opted for expectant management until the next day.
34. Unfortunately, based on the evidence available we cannot determine exactly what was said during the conversation, as we have conflicting accounts that are hard to resolve. We recognise Miss L’s upset that the medical team did not give her the option to transfer to a different hospital, so we considered if there were indications the Trust should have transferred her.
35. In Miss L’s case, her baby was known to be concerningly small and needed to be monitored closely. There was end-diastolic flow in the umbilical artery, and at the time her baby’s movements were present, and the CTG results were reassuring. There were no indicators that imminent delivery of her baby was required.
36. On balance, we think the medical team had a conversation with Miss L about transfer to another hospital and took advice from the paediatric team about the plan going forward. There were no indications that the delivery of Miss L’s baby was imminent, so transfer to another hospital was not required. This is in line with the GMC and RCOG guidelines above.
No action was taken to deliver Miss L’s baby earlier
37. The medical team did not consider immediate delivery on the morning of 26 January was necessary and CTG findings were reassuring. As there was no immediate risk the baby was hypoxic (low levels of oxygen in the baby’s tissues) it was felt that conservative management was appropriate, and delivery was not deemed necessary.
38. We cannot see any indication that Miss L’s baby should have been delivered sooner. This is because the CTG monitoring showed her baby to be non-hypoxic, and no other concerns were noted. It was therefore appropriate to continue inpatient monitoring. This is in line with RCOG guidelines which do not recommend delivery in a baby under 32 weeks’ gestation in these circumstances.
39. We understand Miss L’s concern that the medical team should have delivered her baby sooner. Our adviser explained that delivery in such a premature baby would have required a very strong indication due to the very significant risk of complications, and at that time it was appropriate to continue monitoring Miss L and her baby.
Staff did not take appropriate action when Miss L reported pain and a change in her baby’s movements
40. Miss L said she told the doctor that her baby’s movements were unusual, and the baby was overactive following decelerations that occurred on the evening of 25 January, and the morning of 26 January and that she was in pain.
41. The Trust said there is no documentation in the medical records to state she was experiencing any pain at this time. It said as she was stable and the baby's condition was reassuring based on the CTG, it was agreed she could leave the unit for mobilisation.
42. GMC guidelines explain that if doctors assess, diagnose or treat patients, they should also promptly provide or arrange suitable advice, investigations or treatment where necessary.
43. We cannot see any reference in the medical records that Miss L was in pain or reference to reduced movements. From the evening of 25 January to the morning of 26 January, Miss L was seen by different staff members and none of them have recorded that she was in pain. There is reference to fetal movements, stating that there was ‘more fetal activity today’ and the CTG on the morning of 26 January showed no evidence of hypoxia.
44. On balance and considering that different staff members saw Miss L, we think these results are reassuring and there was no action that needed to be taken at that time. This is in line with GMC guidelines.
Miss L’s request for a scan on 26 January was declined
45. Miss L complains she asked the obstetrician for a scan on the morning of 26 January. The Trust said an obstetrician would only carry out a scan in exceptional circumstances.
46. Our adviser explained that ultrasound scanning (uses sound waves to build a picture of the baby in the womb) cannot be used to diagnose placental abruption and the diagnosis is made clinically from the presence of abdominal pain and/or vaginal bleeding, and sometimes (in severe cases) evidence of hypoxia on a CTG.
47. On call (out of hours) obstetricians usually only have access to portable scanners which, when a departmental scan has been carried out very recently (in Miss L’s case an ultrasound scan was carried out on 24 January) will add little to the clinical picture.
48. In this situation, we do not think a scan was necessary on the morning of 26 January. This is in line with GMC guidelines which state that in providing clinical care, doctors should arrange investigations where necessary.
Staff missed signs of a placenta abruption
49. Miss L says the medical team missed the placenta abruption. In its complaint response, the Trust said a placenta abruption cannot be predicted and therefore it cannot be prevented.
50. Placental abruption is, as explained above, diagnosed clinically with symptoms of pain, and/or vaginal bleeding, and/or evidence of hypoxia on a CTG.
51. From the evidence we have seen, there is no reference to any bleeding or pain in the medical records prior to the placenta abruption. The last CTG completed on 26 January, showed no evidence of hypoxia and was reassuring when considering the baby’s gestation of 30 weeks.
52. We do not think the Trust missed signs of placenta abruption and Miss L’s care was in line with GMC guidelines which says that if doctors assess, diagnose or treat patients, they must take account of their history, and where necessary examine the patient and arrange suitable investigations.
53. The evidence indicates the Trust assessed Miss L appropriately and her symptoms did not indicate a placenta abruption. It appears the sad loss of Miss L’s baby was a sudden event, and we are sorry to hear of the distress caused to her and her family.
54. We are sorry to hear of the impact of the events on Miss L. We recognise from conversations we have had with Miss L how difficult it has been for her losing her baby. We have not identified that anything went wrong in Miss L’s care and therefore we are not taking further action on the complaint. We hope our decision provides some reassurance to Miss L about the care and treatment provided to her.