23. Ms D feels the verbal consent she gave staff during labour and afterwards was not valid given she was in extreme pain. This refers to verbal consent given for intervention in the labour through instrumental delivery, vitamin K given to her baby via injection instead of oral and for an active third stage of labour.
Pain relief before instrumental birth
24. Ms D says the Trust did not give her effective pain relief before beginning the instrumental birth. She tells us her baby was at station +1, meaning she should have received spinal or epidural anaesthetic.
25. Ms D had initially planned to have a caesarean before going into labour at home and deciding on a home birth. Staff took her into hospital as she had passed significant meconium which can be a sign of foetal distress. She arrived on the ward at 11.43pm and at 12.00am an obstetrician recommended an urgent instrumental birth as she was at high risk of post-partum haemorrhage.
26. Royal College of Obstetricians and Gynaecologist’s Green-top Guideline No. 26 on ‘Assisted Vaginal Birth’ says doctors should ensure that appropriate pain relief is provided before beginning an instrumental birth. What constitutes appropriate pain relief depends on where the baby is within the pelvis. For a low pelvic birth this will be a perineal block (anaesthesia to numb the area between the vagina and anus) and for a mid-pelvic birth this will usually be a regional block (anaesthesia that numbs a large part of the body).
27. We were unable to read handwritten records around the station of Ms D’s baby. Whilst the Trust says these show the baby was station +2 (low pelvic), Ms D provided us with an email from the obstetrician who wrote the notes clearly stating that the baby was station +1 (mid pelvic).
28. Ms D received Entonox (gas and air) as well as a perineal block (local anaesthetic within the area between the vagina and anus) in the 16 minutes between the obstetrician recommending an instrumental birth and Ms D giving birth.
29. Our adviser explained that a regional block in the situation means an epidural or spinal anaesthetic. They said that whilst clinicians would usually provide this anaesthetic for a midpelvic birth, the guidance does not say this must always be the case. This is especially true in an emergency.
30. We also discussed this with our internal physician adviser. They said that whilst appropriate analgesia for a mid-pelvic birth will usually be a regional block, the urgent nature of the situation meant the practicalities of providing this may not have been possible. For example, an anaesthetist may not have immediately been available.
31. They explained that for Ms D to have a spinal or epidural anaesthetic before the instrumental birth began clinicians would have had to:
• ask an anaesthetist to attend • wait for them to arrive • wait for them to set up the anaesthesia.
32. NHS.uk webpage on ‘Epidural’ says that this involves an anaesthetist placing a drip in the arm, giving an injection of local anaesthetic and inserting an epidural catheter into the spine. The anaesthetist will give pain relief medicines through the catheter. These take between 20 to 30 minutes to take full effect.
33. General Medical Council’s guidance on ‘good medical practice’ says doctors must promptly provide suitable and effective treatment based on the best available evidence.
34. Our physician adviser said it was clear that the situation required urgency, as only sixteen minutes passed between the obstetrician recommending an instrumental birth and Ms D giving birth. They said it may not have been possible for clinicians to promptly provide an epidural or spinal anaesthetic in line with GMC guidance.
35. We recognise that Ms D feels a failing in care occurred as she did not receive a spinal or epidural anaesthetic before clinicians began the instrumental birth. The guidance does not oblige clinicians to provide this for all mid pelvic births. Meaning we cannot say that service failure occurred. On the balance of probabilities, we consider it likely that it was not possible for clinicians to provide Ms D with a spinal or epidural anaesthetic before she gave birth.
36. Ms D tells us she was in immense pain during the instrumental birth. Our advisers noted that giving birth for many people is a painful process. Things which are unmeasurable such as anxiety and fear influence how a person experiences pain. We accept that an epidural or spinal anaesthetic would have given her more widespread pain relief than a perineal block, as these numb entire regions of the body.
37. GMC guidance clearly stipulates that doctors must promptly provide suitable treatment based on the best evidence available. Our internal physician said in this situation it was up to the obstetrician to make a clinical judgement of the best possible way to tackle Ms D’s pain within the limitations of the situation.
38. Clinical notes state ‘effective analgesia achieved’ suggesting the obstetrician believed the pain relief Ms D had received was good enough. Our physician explained that if this was the case we would not expect the obstetrician to do anything further regarding pain relief.
39. We understand that Ms D found the instrumental birth very painful. We do not dismiss how distressing this experience was for her. We accept that the pain relief she received may not have been effective, the evidence suggests this was unavoidable due to the urgent need for care.
40. For us to say a failing occurred, we must be able to see that what happened fell so short of an expected standard that it constitutes a service failure. We consider it likely that clinicians did not have enough time to provide Ms D with an epidural or spinal anaesthetic. We recognise this meant that Ms D received pain relief that was not as effective as a regional block would have been.
41. On balance we consider the obstetrician promptly provided Ms D with the best available pain relief given the emergency nature of the situation. This was in line with GMC guidance. Whilst we accept the pain relief was not effective for Ms D, the evidence suggests this was unavoidable. We have not found a failing in this aspect of complaint. We recognise this will be disappointing to Ms D as she strongly asserts she should have received a spinal or epidural anaesthetic.
Validity of verbal consent
Instrumental delivery
42. Ms D feels the verbal consent she gave for intervention in the labour through instrumental delivery was not valid due to the amount of pain she was in.
43. Our adviser reviewed the records and said it was clinically appropriate to recommend an instrumental birth to Ms D. They explained she was of advanced maternal age at 50-years-old, had four previous babies, a scar on her uterus and thick meconium in labour all of which placed her at higher risk. In addition to this the recording of the baby’s heart rate showed it was dipping with each contraction.
44. In its letters and responses, the Trust said verbal consent was obtained for all above interventions.
45. The relevant guidance for consent is General Medical Council guidance on ‘Consent: patients and doctors making decisions together’. This says patients can give consent orally or in writing.
46. Our adviser said women are generally in pain during labour. The records show Ms D allowed vaginal examination and subsequently put her feet on stirrups to allow for assisted vaginal delivery to occur. Our adviser explained this suggests she understood the information health care professionals provided, processed it and as a result, agreed for the assisted vaginal delivery to go ahead and to be concluded. They said there is no indication that her consent was invalidated by pain.
47. The clinical records document Ms D was in pain during labour and was at times screaming. We recognise the distress she felt at having such a medicalised birth when she had planned for a home birth. Nowhere in guidance does it describe situations where pain may invalidate consent, only that doctors must ensure consent is given before providing treatment. Whilst we do not dismiss the level of pain she experienced, in seeking clinical advice we understand that pain is common during labour.
48. The evidence suggests Ms D was able to agree to the instrumental delivery despite her pain. We consider the Trust acted in line with GMC guidance as they obtained consent before commencing treatment. We have not found a failing in this aspect of complaint.
Vitamin K
49. Staff gave Ms D’s baby vitamin K via injection. Ms D feels the consent she gave for this was invalidated by her pain.
50. Both Ms D and the Trust agree verbal consent occurred. In our provisional views, we said we had been unable to locate any documentation of a discussion around this nor when staff administered the injection. In response to our provisional views the Trust provided us with a document that clearly states, ‘vitamin K first dose given with consent’. Staff completed this document after Ms D had given birth at around 12.16am.
51. We still do not have enough information to establish exactly when staff gave the injection, meaning we cannot say with any certainty how much pain Ms D was in or reach a decision on whether this pain was severe enough to invalidate her consent.
52. We considered whether we could expand on this point of complaint by interviewing specific Trust staff.
53. We are aware Ms D had a post-natal meeting on 4 November 2020, and the Trust informally responded to her concerns across three letters and in its complaint response dated 9 September 2021. It also provided comment on this area in response to our provisional views.
54. We feel it is unlikely that individual staff can provide any new information on this point of the complaint, given that it has been almost four years since events.
59.Our approach to balancing evidence is that we will take full account of both the complainant’s and organisation’s evidence to reach an independent view. We will consider all evidence without bias and evaluate this to reach an impartial decision.
55. We have taken full consideration of Ms D account of events over multiple phone calls during our primary and detailed investigation of her complaint. She feels she was in so much pain her consent for vitamin K was not valid. The Trust does not comment on the validity of consent but states a midwife discussed the decision with Ms D and obtained her consent. As we said above, nowhere in guidance does it describe situations where pain may invalidate consent, only that doctors must ensure consent is given before providing treatment.
56. For us to say a failing occurred, we must be able to see that what happened fell so short of an expected standard that it constitutes a service failure. Whilst both parties accept consent occurred, we do not have enough independent information to reach a view on whether this was valid or not. In the circumstances, we cannot make a robust decision about what is more likely to have happened meaning we cannot say a failing occurred. This is largely because of gaps in record keeping. We go onto explore this in detail in a later part of this report.
Active third stage of labour
57. Ms D feels the verbal consent she gave for an active third stage of labour was invalidated by her pain. The third stage of labour is between the baby being born and the placenta coming out.
58. In its letters and responses, the Trust does not comment on the validity of consent. It states staff ensured that verbal consent was obtained for all above interventions.
59. In its letter dated 19 February 2021 the Trust explained Ms D had risk factors for a post-partum haemorrhage (heavy bleeding after birth) which included an instrumental delivery and a long second stage of labour. It said it offers an active third stage of labour to any woman who has risk factors for a post-partum haemorrhage, even if the birth plan states a woman wishes to have a natural birth. This is to make sure the woman is continuing to make an informed choice as the clinical picture can change.
60. The third stage of labour is defined as the period between delivery of the foetus through delivery of the placenta. Active management of the third stage consists of a range of interventions which aim to accelerate delivery of the placenta and increase uterine contractions with the goal of preventing post-partum haemorrhage.
61. Our adviser reiterated that Ms D was of advanced maternal age at 50-years-old, had four previous babies, a scar on her uterus and thick meconium in labour all of which placed her at higher risk. In addition to this the recording of the baby’s heart rate showed it was dipping with each contraction. They explained this meant an active third stage of labour was clinically appropriate.
62. The relevant guidance for consent is General Medical Council guidance on ‘Consent: patients and doctors making decisions together’. This says patients can give consent orally or in writing. In cases that involve higher risk it is important that you get the patient’s written consent. This is so everyone agrees what was explained and agreed.
63. If it is not possible to get written consent, for example in an emergency, doctors can rely on oral consent. They must still give the patient the information they want or need to make a decision. The guidance states doctors must record the fact that the patient has given consent in their medical records.
64. When recording decisions, doctors must use the patient’s medical records to record the key elements of discussion with the patient. This should include any information the doctor discussed, any specific requests by the patient and details of any decisions made.
65. Ms D says she only gave verbal consent for an active third stage of labour. In her emails between July and August 2024 explained she did not give written consent for this, and only gave written consent for the repair of what went wrong during the third stage.
66. The clinical records contain a consent form. This states the name of proposed procedure or course of treatment as ‘FUA (follow up after) and manual removal of placenta’. Our adviser reviewed this and noted it shows detailed consent for third stage management. Ms D signed this which suggests she gave written consent, not verbal.
67. It is not clear from the records exactly what time Ms D signed this form, although we accept it was after giving birth as an active third stage of labour involves an injection and cord clamping to help deliver the placenta. We understand at this stage Ms D had postpartum haemorrhage and had undergone an episiotomy.
68. GMC guidance says it is important doctors get written consent in high-risk situation. We understand Ms D had a post-partum haemorrhage and had undergone an episiotomy. Our adviser confirmed this constituted a high-risk situation, therefore written consent was appropriate.
69. We understand Ms D feels the level of pain she was experiencing meant that her consent was not valid. Whilst we accept she was in immense pain, we have not seen sufficient evidence to say this pain invalidated her consent.
70. The clinical records show written consent for active third stage management, suggesting Ms D consented to this. We recognise she disagrees with this, as she strongly asserts she only consented to staff treating complications of third stage management. We have not seen any independent evidence to support Ms D’s account of events.
71. The evidence we have seen suggests that Ms D gave written consent for third stage management. Staff documented this consent in line with GMC guidance. We have not found a failing in this aspect of the complaint.
Episiotomy
72. Ms D complains the Trust did not obtain consent to perform an episiotomy. She states that staff did not discuss why the episiotomy was needed or if she would prefer a natural tear.
73. In its letter dated 15 March 2021 the Trust said staff felt an episiotomy was necessary to expedite delivery. It explained episiotomies are commonly used for instrumental deliveries to avoid tearing to the perinium. It said staff obtained verbal consent for an episiotomy as part of discussions around assisted delivery.
74. The relevant guidance for this aspect of the complaint is RCOG Green Top Guideline No 26. This states staff should discuss episiotomy with the woman as part of the preparation for assisted vaginal birth. It says staff should document the discussion in the clinical notes.
75. As we set out in an earlier section, GMC guidance states consent can be verbal or written. It goes on to say that regardless of the format of consent, doctors must use the patient’s medical records to record the key elements of discussion with the patient. This should include any information the doctor discussed, any specific requests by the patient and details of any decisions made.
76. We have been unable to locate any record of a discussion about an episiotomy. This means we cannot establish what was said and whether an episiotomy formed part of any discussion around assisted birth. As with the section of this report around vitamin K, we do not feel that individual staff can provide any new information on this point of the complaint, given that it has been almost four years since the period of complaint.
77. There is a clear difference between the Trust’s and Ms D’s point of view. We considered whether we could reach a view on balance of probabilities on this aspect of the complaint. While the Trust strongly asserts that Ms D gave verbal consent for an episiotomy, we have been unable to support this with information from her clinical records.
78. Ms D feels she did not consent for an episiotomy, yet in her letters she describes gaps in her memory of her labour due to the pain and distress she experienced. We do not feel we have enough evidence to give weight to either account of events because of this, therefore we cannot reach a balance of probabilities view.
79. For us to say a failing occurred, we must be able to see that what happened fell so short of an expected standard that it constitutes a service failure. We do not have enough information to say what happened around this aspect of complaint. Meaning we cannot reach a robust view regarding failings. This is largely because of gaps in record keeping. We go onto explore this in detail in a later part of this report.
Information about instrumental birth
80. Ms D complains that staff did not give her all relevant information when asking her to agree to an instrumental birth.
81. In its letters and complaints responses the Trust says staff told Ms D why an instrumental birth was necessary.
82. As we have already explained (paragraph REF _Ref171689787 \r \h \* MERGEFORMAT 43) it was clinically appropriate for staff to ask Ms D to agree to an instrumental birth as she was deemed at high risk of post-partum haemorrhage.
83. General Medical Council guidance on ‘Consent: patients and doctors making decisions together’ states doctors must record the fact the patient has given consent in their medical records. When recording decisions, doctors must use the patient’s medical records to record the key elements of discussion with the patient. This should include any information the doctor discussed, any specific requests by the patient and details of any decisions made.
84. As with other sections of this report, there is no record of what was said during the discussion about an instrumental birth. As we set out in the first section of this report, it is clear a discussion took place, and that Ms D did consent to an instrumental birth. The lack of documentation means we cannot establish whether staff gave her all the relevant information when asking her to consent to this.
85. Our adviser said that whilst it would be not expected or proportionate for staff to have an in-depth and detailed discussion given the emergency situation, we would expect to see the discussion documented.
86. There is a clear difference between the Trust’s and Ms D point of view. We considered whether we could reach a view on balance of probabilities on this aspect of the complaint. Whilst the Trust feels it gave Ms D enough information when asking her to consent to an instrumental birth, we have been unable to support this with information from her medical records.
87. Ms D feels staff did not give her all the relevant information. In her letters to the Trust, she asks questions about what happened, as she cannot fully remember. We do not feel we have enough evidence to give weight to either account of events because of this, therefore we cannot reach a balance of probabilities view.
88. For us to say a failing occurred, we must be able to see that what happened fell so short of an expected standard that it constitutes a service failure. We do not have enough information to say what happened around this aspect of complaint. Meaning we cannot reach a robust view regarding failings. This is largely because of gaps in record keeping. We go onto explore this in detail in a later part of this report.
Reason for intervention being necessary
89. Ms D complains that an obstetrician inaccurately selected ‘urgent need for delivery (CTG)’ as the reason for intervention being necessary.
90. In its response to the complaint dated 9 September 2021 the Trust explained the decision for instrumental delivery on the electric record is an option the doctor chose from a pre-populated list based on his clinical opinion.
91. Our adviser said there are no specific standards or guidelines obstetricians must follow when entering a reason for intervention in birth onto a person’s medical records.
92. Ms D feels the reason the obstetrician selected was inaccurate. The clinical records show that the obstetrician recommended intervention in the birth because of several reasons. These included Ms D’s higher risk of post-partum haemorrhage and the baby’s heartrate dropping for a period of time. CTG stands for cardiotocography which is a technical means of recording a baby’s heartrate during pregnancy.
93. The Trust said clinicians select reasons for intervention from a pre-populated dropdown list. On the balance of probabilities, we consider it likely that it was only possible for the obstetrician to select a single option, and having reviewed the records, we can see that CTG was one of the reasons for selecting intervention.
94. In lieu of specific guidance, we refer to General Medical Council’s guidance on ‘good medical practice’ which says when providing care clinicians must keep clear and accurate records which report the relevant clinical findings and decisions made.
95. The evidence shows that one of the reasons clinicians recommended intervention in the birth was the baby’s heartrate dropping and this is what the obstetrician selected from the drop-down list. Whilst we recognise Ms D does not agree with the option the obstetrician chose, we are not persuaded the option was wrong.
96. GMC guidance says doctors should accurately record decisions made. We can see the option the obstetrician chose was one of several accurate reasons available. We consider the obstetrician acted in line with GMC guidance on this aspect of the complaint. We have not found a failing in this aspect of the complaint.
Record keeping
97. Ms D complains about the Trust’s record keeping during the period of complaint. She says clinicians did not appropriately record consent for:
• intervention in labour through instrumental delivery • vitamin K given to her baby by injection instead of orally • a managed third stage of labour • an episiotomy.
98. She says staff did not document decisions to proceed without written consent and the reasoning for this in her medical records.
99. In its response to our proposal to investigate the Trust noted that a large portion of Ms D’s complaint relates to consent. It said Ms D gave verbal consent throughout her birthing experience. It notes that the Department of Health’s reference guidance for consent for examination or treatment states the validity of consent does not depend on the form in which it is given.
100. The Trust recognised that Ms D feels a lack of valid consent impacted her ability to make an informed decision. It said clinicians discussed the rationale and decision for instrumental delivery with her but did not document this until after care had taken place.
101. Department of Health’s reference guidance for consent states that for consent to be valid it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question.
102. To give valid consent, the person needs to understand the nature and purpose of the procedure. In considering what information to provide, the health practitioner should try to ensure that the person is able to make an informed judgement on whether to give or withhold consent.
103. The GMC provides guidance on the type of information that patients may need to know before making a decision and recommends that doctors should do their best to find out about patients’ individual needs and priorities when providing information about treatment options.
104. Royal College of Obstetricians and Gynaecologists clinical governance advice No. 6 on ‘obtaining valid consent’ says verbal consent should be obtained which should be witnessed by another care professional. Obstetricians and the witness to verbal consent must record the decision and the reasons for proceeding without written consent.
105. GMC guidance states keeping patient’s medical records up to date with key information is important for continuity of care. Keeping an accurate record of the exchange of information leading to a decision in a patient’s record will inform their future care.
106. The guidance explains doctors should take a proportionate approach to the level of detail they record. Good medical practice states they must include the decisions made and actions agreed and who is making the decisions and agreeing the actions in the patient’s clinical records.
107. The records show Ms D arrived at hospital at 11.43pm. At midnight doctors noted ‘decision for instrumental delivery’. At 12.13am an episiotomy took place and by 12.16am Ms D had given birth. Around 14 minutes later staff noted ‘doctor consenting to manual removal of placenta’.
108. Most of the decision making took place in less than an hour and there are minimal contemporaneous notes of discussions or consent. Our adviser explained it would not be proportionate for clinicians to have in-depth, detailed discussions or make extensive notes at the time as it was an emergency. They said in this context, verbal consent would be valid.
109. In seeking clinical advice, we understand that in this situation, clinicians should ensure another care professional witnesses the verbal consent. The deciding clinician and witness must record the decision and the reasons for proceeding to any emergency delivery without written consent.
Instrumental birth and vitamin K
110. In her complaint to us, Ms D accepts that she gave verbal consent for an instrumental birth, vitamin K and an active third stage of labour. She disputes the validity of this consent and notes the Trust cannot support its view using her medical records.
111. We have not found any failing around consent for an active third stage of labour. The records show detailed consent for third stage management including a signed consent form.
112. GMC guidance makes it clear that records should accurately document clinical findings and decisions made. When obtaining consent, clinicians should document what was discussed.
113. Whilst we recognise the Trust says it obtained verbal consent for each intervention, and the delivery summary states ‘verbal consent obtained’. We have been unable to locate specific documented consent for intervention in labour through instrumental delivery and vitamin K given to her baby by injection instead of orally.
114. Our adviser reviewed the medical records and noted that for each intervention, clinicians did not document verbal consent at the time it was given, nor the reasons for proceeding without written consent.
115. As we explain in an earlier section of this report, staff did not document what they discussed with Ms D when asking her to consent to an instrumental birth or vitamin K. We recognise the emergency nature of her condition may have prevented staff from recording what was said at the time of events. But the guidance cited above is clear that consent must be documented, even if that is done in retrospect. This was not done, and we have identified two failures in record keeping.
Episiotomy
116. Ms D complains that clinicians did not record her consent for an episiotomy, or any discussion on whether it asked if she would prefer a natural tear.
117. Our adviser explained that clinicians would typically gain separate consent for an episiotomy. As with the above sections, we recognise the decision to perform an episiotomy took place during an emergency and it would not be reasonable to expect clinicians to make detailed notes of what was discussed prior to carrying this out. Our adviser explained staff should have documented this after the emergency was over.
118. GMC guidance makes it clear doctors should keep an accurate record of the exchange of information lead to a decision in a patient’s record. There is no documentation of any exchange of information around an episiotomy in Ms D records. This means we cannot establish whether an episiotomy formed part of any discussion around assisted birth. This is a further instance of poor record keeping.
119. Whilst we recognise all interventions were medically necessary, there is minimal documentation of conversations between staff and Ms D in her medical records. This has actively prevented us from reaching a robust decision on several areas of complaint. We have identified repeated instances of poor record keeping and consider there is a failing in this aspect of the complaint.
Impact
120. We will now consider what impact the failings we have identified had on Ms D.
Physical impact
121. Ms D says the Trust’s actions caused her immense pain. As we said above the Trust provided Ms D with clinically appropriate pain relief. Also, we have found no failings in the treatment the Trust provided to Ms D. This means we cannot link the pain Ms D experienced with any fault on the Trust’s part.
122. Ms D also says that lack of consent left her with postnatal depression and posttraumatic stress disorder. We have not been able to reach a view on failings around consent due to poor record keeping.
123. From our previous work on complaints about birthing experiences, we understand that postnatal depression and post-traumatic stress disorder are mental health issues that can occur after childbirth. Both conditions are more common with women who have traumatic birthing experiences. NHS.UK webpage on post-natal depression explains this affects more than one in ten women within a year of giving birth.
124. We do not consider we could ever link Ms D’s postnatal depression and PTSD solely with the Trust’s actions. For us to be able to link Ms D’s claimed impact with the Trust’s actions, we would have to be able to say with certainty that she would not have experienced postnatal depression and PTSD had failings not occurred.
125. It is clear from the available evidence that Ms D wanted a natural home birth, and unavoidable circumstances led to her having a highly medicalised traumatic birth in hospital. This change in birthing plans is traumatic by nature and it is possible this trauma may have led to Ms D experiencing postnatal depression and PTSD regardless of any failings. We cannot link a physical impact to the failings we have identified.
Emotional impact
126. Ms D says the Trust’s poor record keeping meant it could not properly answer her complaint or provide her with reassurances. She explains this has caused her distress and she has developed a mistrust of medical professionals.
127. As we explain in an earlier section of this report, the failings around record keeping affected our ability to reach a robust decision around consent. Ms D and the Trust’s account of events are contradictory and there is not enough independent evidence for us to reach a view. This will impact Ms D as we are unable to give her closure.
128. We recognise this is frustrating, distressing and worrying. The Trust has been unable to properly answer her complaint as it cannot support its answers with information from her medical records. We consider she will never get a full answer to her complaint as the record keeping is so poor.
129. We cannot fully quantify the impact of this. Whilst we would expect this to lessen over time, we cannot say it will fully go away. It is clear from Ms D’s account of events that she was in pain and distress during the period of complaint and understandably has gaps in her memory because of this. We consider she should be able to rely on her medical records to understand what happened and is unable to do so due to the failings around record keeping. We consider the Trust’s actions prevented Ms D from having definitive answers about what happened during and after her labour.
130. We refer to our severity of injustice scale when deciding what an organisation should do to put right impact. This helps us provide fair and consistent remedies. The scale has six levels ranging from level one injustices of emotional upset or minor pain and discomfort up to level six injustices where significant profound and devastating failings have occurred such as the loss of life or impacts causing permanent disability or avoidable death.
131. Having reviewed the Trust’s responses to Ms D, we can see it apologised that she was left distressed and disappointed by her birthing experience. It explained it had discussed the importance of shared decision making and consent with the doctor involved in Ms D’s care and they would receive training on this.
132. Whilst the Trust acknowledged documentation of consent could have been better, we cannot see it has identified or addressed the full extent poor record keeping or how this has impacted Ms D. We cannot see the Trust has taken steps to ensure this does not occur again. We consider there is more for the Trust do to prevent this from happening again in the future.
133. It is difficult to separate the impact caused by the traumatic birth from the impact of any failings. But we accept that the Trust’s poor record keeping had a lasting impact for Ms D as she will never get a full answer to her complaint.
134. In bringing the complaint to us, Ms D would like the Trust to apologise for its mistakes. She would also like it to make service improvements to prevent these issues from occurring again in the future.