Telephone call
18. Mrs O told us she had three consecutive ectopic pregnancies resulting in miscarriage prior to this pregnancy. We are saddened to learn of her experience.
19. On 17 November 2021 Mrs O says she called her GP practice to enquire about having an early scan, she was six and a half weeks pregnant at this time. Mrs O spoke to a midwife at the GP practice and informed her of her previous pregnancies. Mrs O told us the midwife said she did not meet the criteria for an early scan. The midwife was part of the community midwifery team which come under the remit of the Trust but hold clinics at GP Surgeries.
20. In the Trust’s response dated 11 February 2022, the Trust says the midwife does not recall a telephone conversation with Mrs O on the 17 November. In the Trust’s response dated 13 April 2022, it again says the midwife cannot recall this telephone conversation but also says the telephone call would have been to arrange a booking appointment, and it is at this appointment that a full booking assessment is completed.
21. We have reviewed Mrs O’s maternity notes and cannot see any evidence of a call having taken place on the 17 November (such as call notes or recordings). We think a call must have taken place at some point to arrange the booking in appointment as appointments are arranged directly with the midwife or a member of the midwifery team and Mrs O had an appointment scheduled for 1 December 2021.
22. For us to be able to investigate a complaint we use information such as what the complainant tells us, information from the organisation including complaint documents, clinical records, relevant policies. Relevant guidance and independent clinical advice. We also consider any contemporaneous documentary evidence which means and documents or recordings produced at the time of the event complained about.
23. Here we have only what Mrs O has told us about the call and the content of her discussion with the midwife. The Trust has twice said the midwife does not remember the telephone call and there are no written records about it. This is not to say we do not believe Mrs O’s account, the lack of evidence poses an evidential problem for us. The absence of further supporting evidence makes it difficult for us to reach a satisfactory decision on what took place.
24. We are an independent organisation whose purpose is to impartially investigate complaints, this means we are unable to give more weight to one parties’ account of events.
25. We understand this will be disappointing for Mrs O. It is not our intention to cause her further upset. As there is a lack of supporting evidence for us to make an impartial decision, we are unable to reach a decision on this part of the complaint.
Scan referral
26. As explained, we are unable to reach a satisfactory decision on the contents of the telephone call which took place on 17 November 2021 and so we are only going to look at what happened on 1 December 2021.
27. On this date Mrs O had a booking appointment with the midwife. She was eight and a half weeks pregnant at the time and gave the midwife her full obstetric history. She says she asked the midwife if she should be having an early scan. The midwife told her there was nothing in her notes to indicate she needed one.
28. Mrs O says she was not referred for an early scan following this appointment on 1 December. We know Mrs O was concerned about her pregnancy due to her previous history. We can understand why an early ultrasound scan was important to her.
29. The Trust says Mrs O attended the appointment in the 1 December 2021 and the midwife took a full history including a past obstetric history. The Trust says the midwife correctly assessed Mrs O as high risk and made a referral for her to see a consultant. It says the midwife also arranged for a 12 week scan (a standard scan). The Trust also says the midwife was unaware Mrs O had a history of miscarriages and therefore she did not meet the criteria for and early scan.
30. The Trust says the midwife checked Mrs O’s GP records to see if there was any additional information with regard to her plan of care which would indicate and early scan and the midwife did not feel there was.
31. The Trust says it is not the usual pathway for midwives to refer to the emergency gynaecology unit (for and early scan) in absence of pain or bleeding.
32. We looked at information recorded in Mrs O’s medical records to see what information the midwife had available at the time.
33. The information collected by the midwife on 1 December included the antenatal risk assessment. The midwife recorded Mrs O as a high risk booking due to the following risk factors:
• raised body mass index (BMI) of 31.8kg/m2 • one previous emergency caesarean section in 2013 • three previous early miscarriages in 2015, 2016 and 2018 (early miscarriage is under 16 weeks pregnant) • left salpingectomy (removal of left fallopian tube) and cyst drainage in 2016, • fibroids.
34. In the risk assessment two referrals are indicated, one to the high-risk clinic due to having three consecutive early miscarriages and another to the vaginal birth after caesarean section clinic (VBAC clinic) due to her previous caesarean section.
35. Our adviser says Mrs O was properly assessed at this appointment, the correct information was collated and the appropriate referrals were indicated.
36. The Trust’s guidance says in section 3.2, ‘Women with a previous history of recurrent miscarriage (3 or more), ectopic or molar pregnancy can self-refer to the Emergency Gynaecology clinic for an ultrasound scan from around 6 weeks’
37. Mrs O’s past medical history met the Trust’s criteria for an early scan.
38. We need to consider should the midwife have referred Mrs O for an early scan.
39. Our adviser says self-referral for early pregnancy scans are ‘common practice’ and do not require a healthcare professional to make a referral. Our adviser says it is well known amongst maternity and gynaecology healthcare professionals this practice exists and women are encouraged to access this service if they need to. This is to improve access to the service, and patients qualify based upon their pregnancy and medical history.
40. This means the midwife would not have been expected to make a referral for Mrs O to access an early ultrasound scan.
41. We found no failings here as there was no duty on the Trust to refer Mrs O for an early scan. We do not uphold this part of the complaint.
42. While we understand our findings here may not be what Mrs O wanted we hope our consideration of her complaint gives her some explanation as to what happened and help bring her some closure to this traumatic time.
Self-referral
43. Mrs O says she asked for a scan at the 1 December appointment. She says the midwife told her an early scan was not indicated.
44. The Trust says the midwife was not aware Mrs O had three previous miscarriages.
45. The midwife took Mrs O’s obstetric history, they correctly and clearly marked on the booking in forms Mrs O’s history of three miscarriages. We consider the midwife was aware of the miscarriages at the booking in appointment.
46. Mrs O says she was very anxious about the pregnancy given her previous three miscarriages. Pregnancy can be an anxious and difficult time for most women however, given Mrs O’s history we can understand she would be very anxious at this stage and we think it is likely she did ask for an early scan.
47. Our adviser told us they would have expected a discussion to have taken place between the midwife and Mrs O about her complex obstetric/gynaecological history, discussing the three previous consecutive miscarriages and tubal surgery.
48. Our adviser explained they would have expected the midwife to discuss how Mrs O was feeling about the current pregnancy, any potential anxiety regarding a future loss, any signs and symptoms. Our adviser says they also would have expected the midwife to have told Mrs O about ‘free access’ to an ultrasound scan, for reassurance and to address any concerns.
49. The NMC Code is professional standards of practice and behaviour for nurses, midwives and nursing associates. All standards apply within the professional scope of practice. The NMC Code says:
‘3. Make sure that people’s physical, social and psychological needs are assessed and responded to
3.3 act in partnership with those receiving care, helping them to access relevant health and social care, information and support when they need it
6. Always practise in line with the best available evidence, to achieve this, you must:
6.1 make sure that any information or advice given is evidence-based, including information relating to using any health and care products or service.’
50. Mrs O has told us the midwife did not tell her about the self-referral. We have seen there was no duty on the midwife to refer Mrs O for the ultrasound however, we would expect the midwife to have told Mrs O the self-referral service was available.
51. As the midwife did not signpost the early scan service, we can see this fell short of the expected standard as set out in the NMC Code and we have seen a failing here.
Complaint response
52. Mrs O says she found the Trust’s responses and comments cold, contradictory, unapologetic and with no assurances it will change its procedures going forward. Mrs O’s mother supported her in making the complaint as she was not well enough to make the complaint on her own.
53. We have read the Trust’s complaint response dated 11 February 2022 and will consider the Trust’s responses to Mrs O’s questions.
54. Question one says, ‘Why, after Mrs O discussed her previous obstetric history twice with the midwife, did the midwife not escalate an early scan?’ The Trust responds: ‘(Mrs O) attended her booking appointment with the midwife on 1 December 2021, the midwife took a full history including past obstetric history. She correctly assessed your daughter as high risk and made the referral for a consultant appointment……. The midwife was unaware that your daughter had a miscarriage when she had her previous tubal surgery for a possible ectopic, which was subsequently found to be a hydrosalpinx therefore, she did not meet the criteria for an early scan appointment as outlined in explanation’.
55. We think this statement is contradictory, as the Trust said Mrs O’s medical history was correctly assessed but the midwife was not aware of the three consecutive miscarriages. We have seen the booking in paperwork and the midwife clearly recorded the three miscarriages.
56. The Trust says the reason for not referring Mrs O was due to the midwife not knowing she had three consecutive miscarriages.
57. Question two of Mrs O’s complaint says, ‘Why, when Mrs O asked "should I not be having an early scan?" did the midwife did not make a referral for one?’ The Trust responds:
‘It is not the usual pathway for midwives to refer to the Emergency Gynaecology Unit in absence pain or bleeding. The midwife was not aware that your daughter had 3 miscarriages and therefore she did not consider that she would meet the criteria for an early scan. …. I am sorry that your daughter felt she was not listened too’.
58. Again, the Trust say the midwife was not aware of the previous miscarriages but we have seen this is not correct as the booking in paperwork was correctly filled out and recorded the miscarriages. Mrs O said she told the midwife about the miscarriages at the appointment and we can see the midwife noted details of each of these.
59. Question four of Mrs O’s complaint asks, ‘Is there a criteria that is to be met for early scan referral and did the midwife check this? If not, why not?’ The Trust responds:
‘National and Trust guidance states that women. with previous recurrent miscarriage (3 or more), ectopic or molar pregnancy can self-refer to the Emergency Gynaecology clinic for an ultrasound scan from around 6 weeks.
The emergency gynaecology staff usually inform women who have suffered a pregnancy loss upon discharge from the department, that they can self-refer and access the Emergency Gynaecology department early for a scan in a subsequent pregnancy. I am sorry that your daughter cannot recall being informed of this when she attended following her miscarriage.
GPs can also refer or signpost the woman to self-refer for an early gestation scan in a subsequent pregnancy at the Emergency Gynaecology clinic, as contact with the midwife is not until a later time in the gestation.’
60. The Trust is accurate in its response when it says women can self-refer however, it does not say the midwife could have advised Mrs O about the self-referral service or asked if she had already had a scan.
61. Mrs O’s previous miscarriage was three years prior to this event. The Trust said it is sorry she cannot remember being informed of the self-service after her last miscarriage. Mrs O says this statement left her feeling incredibly guilty as if it was her fault she did not remember about the service. Mrs O said she felt like the Trust was blaming her and it was her fault she did not remember information from three years ago, given to her immediately following a miscarriage. She is unhappy with this comment as she feels it places the responsibility on her to get the scan, but she was not aware she could selfrefer.
62. We can understand why Mrs O is unhappy with this comment. There is no evidence to say Mrs O was given this advice and we consider it unreasonable to expect a patient to remember what was said to them three years earlier, particularly following an emotionally traumatic event such as miscarriage.
63. In question ten of her complaint, Mrs O asks, ’Given Mrs O’s previous history, does the Trust agree that an early scan was necessary?’ The Trust’s response says:
‘According to Trust guidance an early scan would have been indicated due to your daughter's recurrent miscarriages, however, as the baby had died at 7 weeks gestation and due to the position of the ectopic, it is unlikely to have changed the outcome as a salpingectomy (removal of the fallopian tube) may have still been indicated. As described above, the GP records did not demonstrate that your daughter had 3 previous miscarriages, which would have triggered the guidance.’
64. The Trust answered the question and then went onto explain the pregnancy was not viable. We do not consider it was necessary to say the medical outcome would not have been any different.
65. Mrs O says she was aware the pregnancy was not viable. She feels the Trust saying this was callous and unnecessary.
66. Question 11 asks, ‘was Mrs O given the correct care given her obstetric history?’ The Trust responds:
‘Following clinical review of your daughter's care, it is difficult to predict whether earlier intervention may have changed the outcome. There are many individual factors when considering safe management of an ectopic pregnancy. As your daughter's pregnancy was a significant size, and her hormone levels were also high, it is likely that surgical management would have been indicated even if an earlier scan was performed, therefore the outcome would have been the same. Even with medical management, there is a risk of persistent trophoblastic tissue (pregnancy tissue) and also an increased risk of an ectopic pregnancy in future pregnancies due to tubal damage’.
67. The Trust did not answer the question posed by Mrs O. Mrs O does not dispute surgical management would have been necessary but says if she had a scan she would have had the surgery earlier. She says she would not have experienced the symptoms of miscarriage and her risk of having a catastrophic bleed would have been reduced.
68. We have seen contradictions in the Trust’s responses, particularly when the Trust says the midwife was not aware of the three miscarriages and we have seen the midwife correctly recorded these.
69. The Trust did not clearly explain midwives do not need to refer for early scans as it is a self-referral service. It did not say why this was not explained to Mrs O.
70. We have also seen instances where the Trust lacks sensitivity in its responses particularly when it said it was sorry Mrs O could not remember what was said to her following her last miscarriage.
71. We have also seen instances where the Trust has not answered the question posed, for example, when it was asked if Mrs O was given the correct care given her obstetric history.
72. The Trust does however, cite the correct guidance of self-referral for early scans.
73. Our NHS Complaint standards are the expected standard organisations should apply when investigating and responding to complaints.
74. The following sections is the relevant guidance here:
‘8.20 Staff who carry out investigations will give a clear and balanced explanation of what happened and what should have happened. They will reference relevant legislation, standards, policies, procedures and guidance to clearly identify if something has gone wrong.
8.21 They will make sure the investigation clearly addresses all the issues raised. This includes obtaining evidence from the person raising the complaint and from any staff involved or specifically complained about.’
75. We consider the Trust’s complaint response of 11 February 2022 fell short of the expected standards. It did not give a clear and balanced explanation of what should have happened, it did not clearly identify if something had gone wrong and there were some questions which went unanswered.
76. Mrs O’s mother wrote to the Trust following receipt of its first response and it responded again on 13 April 2022. We think this second response was appropriate and in line with our standards. It was a more considered and empathetic response, all the questions were answered straightforwardly citing the relevant guidance and there were no contradictions.
77. We have seen a failing in how the Trust responded to Mrs O’s complaint on 11 February 2022.
Impact 78. We have found failings in the Trust not telling Mrs O she could self-refer for an early ultrasound scan, and we have seen failings in communication with the Trust’s first complaint response. We will consider the impact these failings had on Mrs O.
79. Mrs O miscarried her previous pregnancies at around seven weeks. She told us when she got past seven weeks without any signs of miscarriage she really thought she was going to have a baby this time and was incredibly hopeful. Given this, we appreciate what happened next was all the more tragic. We now know she sadly miscarried again at around seven weeks.
80. On 9 December, when she was nine and a half weeks pregnant Mrs O started spotting which can be a sign of miscarriage. She called 111 and was advised to go to hospital. Mrs O says when she got to hospital and she learnt the pregnancy was not viable, she was devastated.
81. Mrs O says if the Trust had given her an early scan or told her she could selfrefer when she asked for an early scan, she would have known the pregnancy was not viable sooner. She says she would not have allowed herself to be hopeful for those two weeks and consequently would not have experienced such devastation and disappointment when she miscarried.
82. Mrs O says losing the pregnancy and subsequent operation meant she had to have time off work and counselling. She moved offices as she could not face talking to colleagues about her pregnancy. Mrs O says she was not listened to by the midwife and it significantly affected her confidence. Mrs O said the ectopic pregnancy left her vulnerable and at risk of having a catastrophic bleed and this is something which still plays on her mind. She says having an early scan would have identified her ectopic pregnancy earlier thereby reducing her risk.
83. Had the midwife advised Mrs O she could self-refer for an early scan at the booking in appointment, the earliest she could have had the scan was 1 December or the next day. The Trust told us the early pregnancy assessment service is available seven days a week, and the next available appointment will be given dependent on individual assessment of need. Most women are seen the same, or next day and it is staffed by healthcare professionals competent in caring for women in early pregnancy. The Trust told us women can self-refer to the service via telephone and they will then be given an appointment to attend the unit.
84. We consider it is likely Mrs O asked for an early scan on the 1 December and had she been made aware she could self-refer for the early scan she would have done so.
85. We have considered the impact of the Trust’s failure to tell Mrs O about the early scan facility where her miscarriage would likely have been discovered sooner. To do this we must try to separate it from the huge impact of the miscarriage itself. We know Mrs O allowed herself to be hopeful about the pregnancy and when miscarried she experienced strong feelings of devastation and disappointment.
86. We consider impact to be a negative effect which is caused by an injustice and is a direct consequence of the injustice. Mrs O has said she allowed herself to be hopeful she would retain her pregnancy, we do not consider this to be a negative effect as hope is largely a positive emotion.
87. We consider the negative effect to be the strong feelings of devastation and disappointment when learning the pregnancy was not going to go full term. We know the Trust was not responsible for the miscarriage as does Mrs O therefore, it is these exacerbated feelings of devastation and disappointment which are the negative impact of the Trust’s failing.
88. When assessing the injustice (impact) of any failings by an organisation, we use our severity of injustice scale (SOI or our scale). This is available on our website. Our scale allows us to think about injustice and remedies consistently and transparently for everyone who uses our service. Within our scale there are six levels of impact.
89. We categorise injustice types by four main categories. These are emotional, material, physiological, and bereavement. These are then broken down into further subcategories. For example, distress under the emotional injustice category or minor pain under physiological injustice.
90. We consider the impact to Mrs O as an emotional type injustice. Emotional impact at level two on our SOI is described as, ‘Distress, worry, annoyance and similar... for a period from 1-2 weeks to about six months.’ or ‘Shorter periods of more serious distress’.
91. Mrs O told us as she did not have a scan and she was not showing signs of miscarriage so she allowed herself to be hopeful the pregnancy was going to be successful. She says to then learn the pregnancy was not viable caused to her to have feelings more intense than the grief and sorrow she would have experienced had she known earlier the pregnancy was not viable.
92. We know Mrs O showed symptoms of miscarriage on 9 December and she went to hospital where an ectopic pregnancy was discovered, she had surgery later that day. This was undoubtedly a traumatic day for Mrs O and would have taken a long time for her to process what had happened.
93. We consider the impact of the Trust’s failing would certainly have lasted longer than two weeks. We know Mrs O was thinking of returning to work after three months. She returned to work after five months as she had a further two months off work due to the upset she experienced over the Trust’s first complaint response.
94. It is difficult to say how long the impact of the Trust’s failing lasted as the emotions Mrs O experienced are intertwined with the miscarriage itself. We do know after approximately three months the impact of events had lessened to a degree where Mrs O felt she could return to work. We cannot determine exactly how much of this period of time is due to the Trust’s failing but we think the impact of this failing likely did not last for more than three months.
95. For an emotional impact to meet our level three description, we would expect this to last between six and 12 months. We think the injustice to Mrs O of the Trust’s failing in communication about the early scan is in line with level two of our SOI.
96. Mrs O told us she had to be signed off work for a further two months after receiving the first complaint response from the Trust. She was devastated by the suggestion she should have known about the self-referral and she was confused by the Trust’s responses. We are sorry to learn of how the Trust’s complaint response letter affected her.
97. The Trust’s complaint handling failing caused an emotional impact to Mrs O. This affected to the extent she took further time off work for a period of eight weeks. We think in our SOI, this is a level two injustice.
98. We do not consider the impact to have lasted so long as to be considered level three or higher as to be so we would expect the impact to have last longer than six months.
99. We have also considered both failings together, whilst thinking about the emotional impact the miscarriage itself would have had on Mrs O. Having done so we think the injustice in this complaint overall is at level two.
100. As an outcome to this complaint Mrs O wants to achieve service improvements and a payment.
101. In the Trust’s response of 13 April 2022, it offered a payment of £250 which Mrs O accepted.
102. The Trust says it will amend the patient information given to women with recurrent miscarriage, to include they can self-refer to the emergency gynaecology service in a subsequent pregnancy. It says it will include this information in the discharge letter sent to the woman’s GP. The Trust says the modern matron for gynaecology reinforced this information with the team at the daily safety huddles.
103. The Trust also says the clinical lead midwife has also reminded all community midwives they can signpost women to self-refer into the service. It is not clear if the Trust made front line midwife staff aware of the self-referral service and whether these staff now know to provide this information to pregnant women where appropriate.