Iron during pregnancy
19. Miss A tells us she has had anaemia (when red blood cells are lower than they should be) all of her life. She says she bled later in her pregnancy because staff did not give her iron supplements to treat this. We appreciate it was a concerning time for Miss A, particularly as she has had problems with anaemia for such a long time.
20. In the Trust’s complaint response, dated 24 March 2023, it said haemoglobin (Hb) levels in the blood show if someone is lacking iron. Miss A’s blood test results on 1 June and 28 September 2022 showed her Hb levels were in normal range so iron was not necessary.
21. RCOG guidelines gives guidance on what Hb levels should trigger treatment with iron. It says these levels should be checked in pregnancy at 13-14 weeks, then at 28 weeks. The end of the first trimester of pregnancy is 13-14 weeks and end of the second trimester is 26-28 weeks.
22. RCOG guidance says anaemia in the first trimester is where Hb is below 110g/l and in the second/third trimester where is falls below 105g/l.
23. Miss A’s clinical notes show on 1 June (14 weeks – end of first trimester) her Hb was 123g/l so a prescription of iron was not indicated.
24. The Trust took Miss A’s blood again on 27 September (28 weeks) and this showed Hb levels as 106g/l which is above the cut-off of 105 at which anaemia is diagnosed.
25. To summarise, the Trust checked Miss A’s Hb when it should have done and was correct not to prescribe iron. This was in line with the guidance. For these reasons, we will not investigate this part of Miss A’s complaint further.
Flu vaccinations during pregnancy
26. Miss A says the Trust did not offer her a flu jab during pregnancy. We are sorry to hear she and baby B caught flu and became ill. We appreciate being ill at this time was upsetting for them.
27. In the Trust’s complaint response, it said Miss A attended a Trust antenatal clinic on 8 April 2023 where staff gave her the whooping cough vaccine. It said staff did not offer her the flu vaccine as it is seasonal and only available between September and March. It said the antenatal clinic offers a drop-in service and the flu vaccine is also available at GP surgeries and pharmacies. The Trust apologised that staff did not explain this.
28. NICE Antenatal care guidelines say that all pregnant women should be given information about immunisation for flu, pertussis (whooping cough) and other infections in line with the NICE guideline on flu vaccination.
29. The UK Health Security guidance says flu vaccine is seasonal and can be given to pregnant women, once it is available between September and March. The Trust could not offer this at Miss A’s antenatal appointment in April. However there is no evidence the Trust gave her information about how and when she could get the vaccine. We recognise the Trust has apologised for this. Miss A says she would have had the vaccine if it had advised her to.
30. The clinical notes show Miss A and B had flu during their admission to the Trust.
31. The UK Health Security guidance says flu vaccine effectiveness varies from one season to the next. It says overall effectiveness is estimated at between 30% and 60%.
32. Our legislation allows us to investigate complaints of injustice. This means we can only investigate where there was a tangible impact as a result of a failing. We recognise Miss A and B unfortunately became ill because of flu. As shown in the UK Health Security guidance, we cannot say they would not have caught flu even if the Trust had advised Miss A to have the vaccine. For these reasons, we are not proposing to look into this any further.
Induction and caesarean section
33. Miss A says staff should not have induced her when they did, because she was bleeding at the time. She also says staff should have provided a caesarean section birth earlier than they did. We appreciate this was an incredibly worrying time for Miss A. We are sorry to hear she was concerned about her and B’s health at what should have been a happy time.
34. In the Trust’s response, it said it is common for some discomfort or slight bleeding after a membrane sweep. This is a procedure where the midwife stretches the woman’s cervix to try to bring on labour. The Trust said when the midwife examined Miss A on the maternity induction unit (MIU) on 31 December 2022, she was not bleeding and there was no blood on her sanitary pads. The Trust said staff were correct to induce Miss A and deliver B by caesarean section when they did.
35. The clinical notes say Miss A asked to be induced and was advised to attend the MIU for a sweep on 24 December, which she did. The records show Miss A again asked to be induced on 28 December and the midwife did a further sweep. The records for both of Miss A’s sweeps do not indicate there was any blood.
36. NICE Inducing labour guidance says staff should offer induction at 41 weeks of pregnancy onwards.
37. The clinical notes show maternity staff induced Miss A on 31 December when she was term (40 weeks) plus ten days. This was in line with guidance. The records do not indicate Miss A was bleeding at the time.
38. Our obstetrician adviser said it is common for a minor bleeding to happen after a membrane sweep. They said, if Miss A had a small amount of bleeding from an earlier sweep, staff were right to go ahead with induction at the point they did. There are no specific guidelines to say this, our adviser said it would be based on the clinical assessment of the midwife. They said the midwife could escalate to an obstetrician if there was significant bleeding but there is nothing to indicate there was. There is no evidence of any other factors of concern at the point staff induced Miss A.
39. Staff decided to deliver B by caesarean section at 8.15pm on 31 December. The records show Miss A was developing a high temperature and B’ heartrate had risen before she was in established labour. This was a decision based on the clinical presentation of Miss A and B and our adviser said staff were right to consider a caesarean birth at that point because of these findings. These findings were not present when staff initially induced Miss A and, as such we consider the caesarean section was done at the right time.
40. For these reasons, we will not be considering this part of the complaint further.
Sodium, potassium and fluids
41. Miss A says staff gave B too much potassium and sodium in the IV drips it used to treat him. We are sorry to hear how his swollen appearance concerned her. We are also sorry to hear Miss A is worried about the long term effects this may have on B.
42. The Trust response said staff did not overdose B and gave him sodium and potassium in line with NICE guidance.
43. NICE guidelines say if a baby needs IV fluid replacement, staff should give routine maintenance fluids for existing fluid and/or electrolyte (essential minerals) deficits or ongoing losses.
44. The guidelines say if required, staff should give this as isotonic crystalloids that contains sodium in the range of 131-154 mmol/L. Isotonic crystalloid means the fluid has the same amount of electrolytes as the blood of the patient. The guidance say staff should use a solution of 0.9% sodium chloride containing potassium to replace ongoing losses.
45. The NICE guidelines say staff should measure plasma electrolytes and blood glucose when starting IV fluids, and at least every 24 hours thereafter.
46. Our adviser explained, in some types of illnesses, particularly respiratory (breathing) conditions, the body produces an excess of the antidiuretic hormone (ADH), which essentially leads to the body retaining more water. Patients with this problem tend to have a reduced urine output, look puffy, and have low sodium levels in their blood (a dilutional effect).
47. The NICE guidelines say, if there is a risk of water retention associated with non-osmotic antidiuretic hormone (ADH) secretion, consider either: • restricting fluids to 50-80% of routine maintenance needs, or • reducing fluids, calculated on the basis of losses within the range 300-400 ml/meter square per 24 hours plus urinary output.
48. The NICE guidelines say, for a baby aged 5-28 days of age, staff should give 120-150 ml/kg/day of IV fluids.
49. Whilst the maximum fluid volumes (150 ml/kg/d) staff gave to B were within the scope of the NICE guidelines, the evidence indicates his body did not cope with this, and our adviser said he experienced fluid overload. This is evidenced by a large positive fluid balance on 10 and 11 January 2023, visible oedema (swelling and puffiness) on 12 January, and excessive urine output on 12 and 13 January. Our adviser said neonatal fluid overload is potentially harmful and should be avoided.
50. B had a positive fluid balance on 9 January and decreasing urine output which indicated water retention. Our adviser said B could have had inadequate ADH secretion at this point. According to NICE guidelines staff should have at least considered this, and the evidence indicates appropriate investigations were not done. Our adviser said this would have better informed the fluid management and could have avoided the overload.
51. Staff initially restricted his fluids due to his breathing difficulties which was in keeping with NICE guidelines. However, on 10 January he was hypernatraemic (high sodium levels in the blood) and the records show staff assumed him to be dehydrated.
52. NICE guidelines also suggest staff calculate the fluid deficit and correct this over 48 hours. The evidence indicates this was not done. Our adviser said if staff had calculated the deficit, the fluid correction would have been much slower.
53. Our adviser said it would be normal practice for staff to closely monitor the fluid balance of a baby on IV fluid replacement, including hourly urine output (at least 12-hourly). NICE guidance suggests staff take a blood sample at least every 24 hours. Staff did not consistently do this. They did not take samples on 12 and 13 January, despite B having high sodium and potassium levels.
54. The evidence indicates staff did not monitor his urine output or fluid balance appropriately and did not realise that any assumed deficit was already replaced in under 24 hours (when they should have done this over 48 hours). Staff kept the same IV fluid volume running for 48 hours until B became oedematous.
55. Staff increased B’s fluids whilst he was at the peak of his respiratory illness. Our adviser said it is not common practice to increase maintenance fluids substantially at this point.
56. Staff gave B isotonic sodium solution (the same concentration as his blood), but as he was given more fluid than he needed, in total terms he was given an excess of sodium. This was indicated by high sodium levels on 11 and 12 January.
57. Staff added potassium to B’s fluids. This was below the daily requirements, however he was generally having high to normal potassium levels and within hours of starting the potassium infusion it rose to a dangerous level (7.3 on a blood gas, 6.6 on a venous sample the following day). Our adviser said it is common practice to stop any potassium infusion, check the level with a venous sample, and obtain an ECG with such high levels. The evidence indicates no action was taken by clinical staff.
58. The evidence indicates doctors did not follow NICE guidelines when managing B’s fluids and electrolytes.
Impact
59. The indications are that the incorrect management of B’s fluids, sodium and potassium led to him being overloaded with fluids. Our paediatrician adviser said this caused his body to become swollen and puffy. We can understand why this caused Miss A concern at the time and worry about what further impact this may have on him. We are sorry to hear it affected her in this way.
60. Having reviewed all the evidence, our paediatrician adviser said they would not expect the events to have any long-term impact on B’s health. We hope this reassures Miss A.
What the Trust has done to put things right
61. Our Principles say we expect organisations to acknowledge mistakes and apologise for the impact these mistakes had. They also say organisations should return the complainant to the position they would have been in if the poor service had not occurred.
62. We contacted the Trust and explained what we have seen so far in relation to the sodium, potassium and fluids. The Trust responded on 22 November and said it would like to resolve the complaint at this stage. The Trust said it would like to: • acknowledge and apologise for what went wrong • make service improvements to ensure the same things do not happen again and • pay Miss A a financial remedy of £100.
63. Miss A agreed this resolves her complaint as this is the outcome she was hoping for. For this reasons we have decided not to take any further action with her complaint.
64. We appreciate the distress Miss A and B have been through and we are sorry to hear it caused Miss A ongoing worry. We hope she is reassured by what we have seen, and that for some aspects of her complaint, the Trust did nothing wrong. We thank Miss A for taking the time to bring her complaint to us and we are pleased we have been able to help resolve it.