13. 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 and have not found any indications something has gone wrong. We have explained our reasons for this decision.
Continuity of care
14. Ms R says there was a lack of continuity of care and poor communication throughout her labour. The Trust apologised for the lack of continuity of care and say although Ms R had several midwives looking after her, these followed the routine shift patterns.
15. NICE Guidance CG190 on intrapartum care says:
• people have the right to be involved in discussions and make informed decisions about their care • ‘maternity services should provide a model of care that supports one-to-one care in labour for all women (1.1.14)
16. NICE Guideline NG229 on fetal monitoring in labour states:
• 1.3.5 Carry out a full assessment of the woman and her baby every hour.
• 1.3.6 Obtain an in-person review of every hourly assessment (see recommendation 1.3.5) by another clinician ("fresh eyes") for women on CTG, to be completed before the next assessment takes place.
17. The notes show Ms R self-referred to maternity triage on 4 August with reduced fetal movements and her blood pressure was also raised. During Ms R’s time in triage, one midwife cared for her. Following clinical review, Ms R transferred to the birth suite for induction of labour (IOL) and her care was handed over to another midwife. This midwife, along with a student midwife cared for Ms R until 8.10pm when her care was handed over to the night staff. At 4:10am another member of staff took Ms R’s observations while the midwife was on her break.
18. Ms R’s care was handed over to the day shift midwife the following morning. At 11.45am, a midwifery care assistant took Ms R’s observations. At 4:14pm another midwife completed a peer cardiotocography (CTG) review. A CTG is used to monitor a baby's heart rate and a mother's contractions during labour. During the night, we can see different midwives conducted an hourly peer review of the CTG. This is in line with paragraph 1.3.6 of NICE guideline NG229 above.
19. On the morning of 6 August, Ms R’s care was handed over to a midwife on the day shift. Again, regular peer review of the CTG took place throughout the day by four different midwives.
20. We can see from the notes, the midwives caring for Ms R during her labour provided care for the whole of their 12 plus hour shift. Our midwifery adviser says there is no indication the midwives were caring for other women whilst they were also looking after Ms R. We appreciate it appeared to Ms R that there were lot of people involved in her care. Often the midwives were accompanied by a student midwife which our midwifery adviser says is usual in all maternity units and we are not critical of this.
21. The notes show both clinical and midwifery staff discussed ongoing plans of care with Ms R (and her partner) during her labour and sought her opinion and agreement to the plans. On 4 August the midwife noted they explained the IOL process to Ms R and she accepted. On 5 August at 8:15pm, a midwife noted they discussed analgesia (pain relief) options with Ms R and they re-discussed this at 10:45pm. At 9:12pm on 5 August a clinician recorded the explained the plan to Ms R that if there was no regular contraction in one to two hours, she would be given further medication to strengthen the contractions. At 6:15am on 6 August, a midwife noted they discussed needing a longer period of CTG trace before administering further pain relief. A clinician reviewed Ms R later that day at 1:20pm and noted they discussed proceeding with a c-section. We consider this is in line with NICE guideline CG190 about involving patients in discussions and make informed decisions about their care.
22. We are sorry to hear about Ms R’s concerns and recognise this was a very worrying time for her. Overall, we consider the Trust provided Ms R with good continuity of care during her labour and staff communicated with her appropriately. We cannot see any indication something went wrong here.
Infection:
23. Ms R says the Trust should have done more to prevent her getting an infection and identified and treated it quicker during labour.
24. In its response letter, the Trust say there were no indications of infection prior to Ms R’s c-section and her observations were within normal parameters. It says at 5:25pm her heart rate was elevated, and she had a raised temperature, so she was immediately commenced on the sepsis pathway. The Trust say none of the blood tests/ swabs showed any bacteria and she may have had a localised infection but not sepsis and the baby had negative blood cultures.
25. NICE CG190 Intrapartum care for healthy women and babies (2014) states:
1.5.1 Transfer the woman to obstetric-led care … (refer for obstetric review) if any of the following are observed at any point:
• pulse over 120 beats a minute on 2 occasions 15 to 30 minutes apart • a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more • either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 15 to 30 minutes apart • respiratory rate of less than 9 or more than 21 breaths per minute on 2 occasions 15 to 30 minutes apart
• a reading of 2+ of protein on urinalysis and a single reading of either raised diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure (140 mmHg or more) • temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings 1 hour apart; for advice about intrapartum antibiotics, see the section on intrapartum antibiotics in NICE's guideline on neonatal infection (NICE ng195 Neonatal infection: antibiotics for prevention and treatment (2021, updated 2024)
26. The Trust use a modified early obstetric warning Score (MEOWS) to allow early recognition of physical deterioration in patients by monitoring their physiological observations such as blood pressure, heart rate and temperature. A score of more than zero triggers the use of a ‘call out cascade’ which gives specific instructions regarding level of monitoring, referral for advice, review, and immediate actions which clinicians need to consider.
27. When Ms R arrived in triage at 1pm on 4 August, her MEOWS score was three because of her raised blood pressure, reduced fetal movements and protein in her urine. At 1:20pm the midwife appropriately called the doctor for review, and they attended at 2pm. The plan of care was for immediate admission for IOL.
28. At 1:30pm when clinicians took Ms R’s observations again, her MEOWS score had reduced to one because of her raised blood pressure. At 8:10pm Ms R’s MEOWS score was two. Although her temperature was within normal limits, her pulse and blood pressure were elevated. The midwives responded appropriately by completing observations again 30 minutes later when the MEOWs score went back to one. By this time, Ms R’s pulse rate had settled to 94 and her temperature was 36.6°C, both of which are within normal limits.
29. At 9:28am on 6 August, Ms R’s temperature was recorded as 39.7°C and the midwife asked for a doctor review. This was in line with NICE guidance CG190 which says care should be referred to obstetrics if the patient’s temperature is 38°C or above on a single reading. The clinical review was completed at 9:40am. At 10.28am Ms R’s temperature had returned to normal and no further action was needed. Ms Rs temperature remained within normal limits for the remainder of her labour.
30. Our obstetrician adviser explains the main indicator Ms R had developed an infection was a rising temperature whilst she was in the recovery area after her c-section. Her temperature at 4:47pm was normal and at 5pm it was mildly raised at 37.4°C. At 5:45pm, Ms R’s temperature was 37.6°C, and at 6:05pm it was significantly raised at 38.6°C. Ms R had a sustained tachycardia (fast heart rate).
31. Para 7 of the contemporaneous RCOG Guideline says ‘abdominal pain, fever (greater than 38 °C), tachycardia (greater than 90/min) are indications for intravenous antibiotics and senior review’.
32. The notes show following Ms R’s temperature reading of 38.6°C at 6:05pm, clinicians decided to commence the sepsis pathway. This which involves taking comprehensive cultures (a test to find germs such as bacteria or fungus) and swabs as well as intravenous antibiotics. A doctor came to review Ms R and started intravenous antibiotics at 6:41pm. This is in line with the RCOG guidelines.
33. Our obstetrician adviser explains that traditionally, sepsis was regarded as a serious systemic bacterial infection (with bacteria found in circulating blood) leading to circulatory instability and the need for medical support of organs such as heart and kidney. There is now a tendency to use the term ‘sepsis’ for any systemic bacterial infection involving a significantly raised temperature. In patients who have recently given birth, this approach is good as an evolving temperature can in some cases lead to overwhelming sepsis in a short space of time. This is why there is a need for prompt management with commencement of broad-spectrum antibiotics to prevent this deterioration.
34. Our obstetrician adviser tells us staff reacted appropriately to Ms R’s rising temperature by taking cultures and starting antibiotics to prevent her from deteriorating. It is not clear where Ms R’s infection originated given the lack of growth of any of the swabs or cultures. As her temperature rose immediately after her c-section, it is likely there was an evolving chorioamnionitis (infection forming within the placenta and membranes within the uterus). This will usually resolve following delivery with antibiotic treatment. The notes show Ms R’s raised temperature gradually settled over the 12-24 hours after starting antibiotics.
35. Our midwifery adviser tells us prior to labour, there was no indication Ms R had an infection. Her temperature on admission to both triage and the birth suite was within normal limits. The midwives undertook observations at the appropriate times and responded to the prompts in the electronic records to increase the frequency of observations and request medical review when appropriate in line with NICE guidance. Our obstetrician adviser says the Trust staff reacted promptly to her rising temperature and undertook appropriate investigations and management. This was in line with RCOG guidance.
36. Overall, we cannot see any indications something went wrong with how the Trust identified and managed Ms R’s infection. We are sorry to hear about the difficult time Ms R had following the birth of her baby, and we hope our decision provides her with some reassurance.