Perineal tear
12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have not seen any indication these issues had a negative impact on Mrs A, over and above that which she likely would have experienced had the tear been diagnosed earlier. We do recognise there was pain and distress related to this, and we do not intend to minimise this in anyway.
13. Mrs A gave birth to her daughter on 8 July 2023 at 5.49am. Following this, she was examined for any genital trauma or damage which might have occurred during labour, and none was found. Later the same day, a further examination was conducted which found Mrs A had indeed experienced a second degree perineal tear. This means there was injury to the perineal muscles but not the anal sphincter. The Trust does not dispute that the tear was missed during the initial assessment, but does not offer an explanation as to why this might have happened.
14. We can see guidance (NICE: Intrapartum care for healthy women and babies) sets out that all women should be offered an examination to assess whether there has been any trauma, and this may be done in the immediate period following birth. From reviewing records, we are satisfied this did happen. However, we also know Mrs A had indeed experienced a tear, and this was not identified at the time. As such, we need to establish whether or not this was reasonable under the circumstances.
15. As part of our consideration, we took advice from a midwife. They explained that the trauma identified on the later examination was a second degree tear on the right vaginal wall. They said it was unclear from documentation whether the fourchette (the skin at the bottom of the vulva, at the top of the perineum) was also involved. This is relevant as tears where the fourchette remains intact can mean there is no obvious sign of a tear on immediate inspection. However, there is no documentation to support this being the case here, and so we cannot establish this to be the reason the tear was missed.
16. In addition, while NICE guidance does set out that the examination of the area should be examined gently and sensitively, we would not necessarily expect pain to have prevented a thorough examination or the area. This is because Mrs A had undergone an epidural, and so it is likely her pain was well controlled. This view was also supported by our adviser, who also explained their view that a thorough examination should have identified a second degree tear involving the muscle.
17. We are mindful that the initial examination noted the perineum to be intact, but that we do not have any accompanying diagrams. Our adviser explained it is common for diagrams to not be included where no trauma has been identified, however this means it is difficult to determine the extent of the examination which took place. We know from the relevant guidance the examination for trauma is to include the relevant structures, such as perineal muscle and anal sphincter, and the extent of any damage. It is intended to rule out all genital tract trauma.
18. Overall, having considered all of the information available to us, we think it is likely that a thorough examination of the area should have identified the trauma during the initial examination. This is because all involved structures are to be examined, it is unlikely trauma was sustained after the birth and it is unlikely pain would have prevented this from being possible in this case. We therefore think this indicates a failing.
19. We therefore need to think about whether there is any unremedied injustice as a result of this. This means considering whether there was any impact as a result of the tear not being immediately diagnosed, and whether the Trust has taken steps to rectify this.
20. We considered what Mrs A had told us about the impact she has felt related to this complaint. We understand she has been through a difficult time, and that it would have been upsetting to find out this tear had been missed. We thought carefully about how her experience differed from what she likely would have experienced if the tear had been identified appropriately following the birth.
21. We think in this case that had the tear been identified, Mrs A would still have been diagnosed with a second degree tear. This is because we have seen nothing in the records or from the advice we received to suggest that later identification meant the injury would have become worse in the time it took to identify it. Therefore, we think it is likely she would still have needed stitches to repair this. She has told us her pain was worse due to the way the wound needed to be stitched following the delay. However, we see the injury was noted later the same day. As we have no basis to suggest the tear would have worsened in that time, we think it is unlikely the repair itself would have been different in any way.
22. We also know Mrs A has told us she had to be rushed back to the labour ward for the repair and was therefore separated from her child. We do not doubt how distressing this would be. Our consideration of this complaint identified the reason for this was because a surgical theatre on the labour ward was available, rather than any emergency need. We cannot say this would have been different had the tear been identified immediately following the birth. It is entirely reasonable the medical team may still have decided to perform the repair in theatre if one was available to do so. We therefore would not be able to establish any impact related to this, as we cannot say the same thing would not have otherwise happened.
23. In addition, Mrs A told us she needed to take antibiotics following her experience. She shared that to her knowledge, she did not have an infection and that these were precautionary due to the tear not being diagnosed sooner. Our nursing adviser also supported this being the case, and we see no evidence of any infection from the records. Mrs A has not told us of any side effects she experienced as a result of the antibiotics, and we know she did not go on to develop an infection, as such we cannot see that taking these antibiotics led to any impact.
24. Finally, Mrs A has told us she needed counselling as a result of her complaint, due to the distress she felt. We are sorry to hear this, and we considered this point carefully. We are firstly mindful that Mrs A is also complaining about a missed diagnosis of a sacral dimple (we will go on to discuss this later), and this has also caused upset for her. Therefore, it would be difficult to establish how much of the distress she has felt relates solely to the delay in identifying the perineal tear. In addition, we must consider that we cannot say the outcome would have been different had the tear been properly identified.
25. As mentioned, we think it is likely the pain would have been similar, and it is entirely possible a surgical theatre would have been used for the repair if it had been identified immediately following the birth. Therefore, it is likely the impact Mrs A felt would not have been prevented, and therefore the trauma she felt would not have been to a lesser extent. This of course does not take away from what Mrs A has been through, and we wish her well in her counselling moving forward.
26. We do appreciate the Trust acknowledged the tear had not been identified during the initial assessment. It notes the midwife involved apologised and would reflect for future improvement. We have not been able to say her experience would have been different if the tear had been identified when it should have been, but we hope it is reassuring that if we had been going to take further action this is the type of action we would recommend to prevent anything similar happening in future.
Sacral dimple
27. Mrs A’s newborn daughter underwent a newborn screening examination (Newborn and Infant Physical Examination - NIPE) on 9 July 2023, where there was no recorded indication of any abnormality of the spine. Mrs A said she later found out that her daughter had a sacral dimple. The Trust acknowledges this in its response to the complaint, but does not explain why this might have been missed.
28. We therefore turned to consider the relevant guidelines (Newborn and infant physical examination (NIPE) screening programme handbook) to establish the expectations surrounding the NIPE. This is a test carried out within the first 72 hours of birth, and again at six to eight weeks. We will refer to these as the 72 hour check and the six week check. It is primarily intended to identify any issues with the eyes, hips, heart, and testes (if the baby is male). The paediatric adviser we discussed this complaint with suggested that this would include a full examination of the baby, including the back and spine. This means that ideally, sacral dimples should be identified.
29. We do see the examination did take place, and the relevant accompanying paperwork was filled in. This is not disputed by either party. We have reviewed the accompanying paperwork, and have no concerns in regards to this being completed correctly. It suggests all relevant examinations took place, including the back and spine, and we see no reason to believe any part of the examination was not completed. Our adviser also did not raise any concerns in relation to this, other than to note the sacral dimple was clearly not identified. We note this does not mean the examination of the back and spine did not happen, but simply that the sacral dimple was not noticed when the examination took place.
30. We know that the sacral dimple was not identified during the NIPE, and so we need to establish if this was reasonable. As such, we discussed this with our adviser. They explained that while sacral dimples should be picked up during the 72 hour check, it is sometimes the case these are not identified until the six week check. This is supported by relevant sources (Sacral Dimples: Advice for Referrers, Sacral dimples and pits).
31. Our adviser explained that sacral dimples are not always easy to see, and this can particularly be the case where they are narrow and deep. They explained it is therefore possible the sacral dimple in this case was not immediately obvious during the 72 hour exam. From what we have seen, it appears Mrs A sent the Trust information from another hospital outlining the appearance of the sacral dimple to be ‘narrow but deep’.
32. Overall, we do not think there are any indications of failings here. While the 72 hour check should ideally identify any sacral dimple, we can see it is established that these can be missed. We think it is likely the back and spine were examined, as the relevant part of the paperwork related to this has been completed, and it is noted there were no abnormalities were suspected.
33. We are also mindful that while the NIPE does include an examination of the back and spine, this is not the primary focus of the examination. With all of this in mind, we do not think it was unreasonable that a sacral dimple was not diagnosed during the 72 hour check. Therefore, we have seen no indication that this being missed was due to any failure in the care Mrs A’s baby received.
34. We do know Mrs A is concerned because her baby needed an MRI scan due to the sacral dimple not being diagnosed earlier. She told us that if it had been noticed during the 72 hour check, a full diagnosis could have been made with an ultrasound scan instead. While this is not central to our decision as we have seen no indication of failings, we know it has caused Mrs A distress. We asked our adviser about this.
35. They confirmed sacral dimples may be diagnosed by ultrasound if the baby is younger than around six weeks, and that later than this an MRI would be needed. This is also supported by the sources we shared earlier (Sacral Dimples: Advice for Referrers, Sacral dimples and pits). However, they also explained it can be the case that further MRI imaging is needed before six weeks old if the ultrasound imaging is inconclusive or unclear. This means it is possible an MRI would have been necessary even if the dimple were diagnosed sooner.
36. Again, while this information does not affect our decision, we hope it will offer reassurance to Mrs A. We know her concern was that her daughter underwent an unnecessary medical procedure she would otherwise not have needed to. We hope by sharing that this may have needed to happen anyway, Mrs A will find this helpful in moving forward.
37. We know Mrs A went through a very difficult time following the birth of her daughter, and we know she has felt a great deal of distress. We know our decision is likely not what she was hoping for, though we hope it will be helpful in answering her concerns.