15. 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 that something has gone wrong.
Failure to conduct an ultrasound scan
16. Miss O says the Trust failed to conduct an ultrasound on 18 October 2022 while she was an inpatient. As a result, she says she felt traumatised where she was diagnosed with PTSD, felt upset, and experienced psychological injuries.
17. We were sorry to hear this was Miss O’s experience and that her mental health has been badly impacted by the circumstances of her complaint. To address her concerns, we reviewed the relevant medical records and discussed them with our adviser.
18. In its response, the Trust said as observations and examination findings were normal, there was no clinical indication for a scan at the time.
19. Our adviser stated, whilst there are various guidelines covering when an ultrasound scan should be offered, this particular instance did not fall into any defined indication. They explained scans are generally undertaken to monitor the health and growth of a baby during pregnancy. This is with a view to helping with a decision on the timing of delivery.
20. The records indicate on 18 October, a midwife performed a CTG at 7.14am and took observations. Foetal heart rate is noted as normal. A midwife performed two further CTGs that same morning, which were also normal.
21. At 12.45pm, an obstetrician reviewed Miss O. They noted normal observations and CTGs. The records indicate they apologised for the delay of the artificial rupture of membranes (ARM), which Miss O was waiting for.
22. A midwife repeated observations at 2.46pm. They documented Miss O’s mother’s concerns about the wait for the ARM and explained staff were waiting for the labour ward to be able to accommodate her. They offered to repeat a CTG for reassurance.
23. The records indicate Miss O remained well throughout the day with irregular contractions. Observations were repeated at 9.40pm.
24. We asked our adviser whether there was any indication for the Trust to perform an ultrasound scan. They explained, in this case, a decision had already been made for delivery prior to 18 October. By this time, Miss O was in the middle of the IOL process. There is generally no need to perform an ultrasound scan during this time.
25. On review of the records, our adviser stated there is a delay between starting and finishing the IOL process. However, Miss O was an inpatient at this time and her baby was being monitored regularly with CTG traces.
26. We consider the evidence indicates Miss O was being monitored via her observations and CTGs. An obstetrician reviewed her during ward rounds and did not raise any concerns.
27. We cannot see any indication for the Trust to perform an ultrasound scan at this time. As explained by our adviser, ultrasound scans are generally used to monitor the health and growth of a baby. Miss O’s baby was being monitored regularly by CTGs, which were all normal on 18 October according to her medical records.
28. On this basis, we consider the Trust has not done anything wrong on this matter. There is no indication for an ultrasound scan, and it would not be needed at this stage of Miss O’s labour. We hope this explanation reassures her that the Trust monitored her and baby appropriately.
Failure to perform a caesarean section
29. Miss O says the Trust refused to perform a caesarean section on 6 and 18 October 2022.
30. As a result, she says she felt stressed, was not listened to, and dismissed. We were sorry to hear this. It must have been distressing for Miss O to feel she was not listened to, and her concerns were dismissed.
31. We asked our adviser whether there was any indication for the Trust to perform a caesarean section on 6 and 18 October. Our adviser told us NHSE guidelines are most relevant for the IOL process.
32. Under ‘raising awareness of FRM’, the NHSE guidelines says ‘in cases of RFM after 38+6 weeks, discuss induction of labour with all women and offer delivery to women with recurrent RFM after 38+6 weeks.’
33. In its complaint response, the Trust says there is no documentation regarding Miss O requesting a caesarean section on 18 October. On review of the records, we also could not see that Miss O requested a caesarean section on either 6 or 18 October.
34. On 6 October, Miss O attended triage with reduced foetal movements. The records indicate a midwife took observations and a CTG, which were normal. The Trust arranged for a follow up in its Antenatal Day Assessment Unit (ADAU).
35. A midwife within the ADAU repeated Miss O’s observations and the CTG. Her observations are noted as within range but with a high heart rate.
36. The records indicate a doppler ultrasound scan was performed at 1.22pm. The findings document good foetal movements which remained imperceptible to Miss O.
37. At 4.22pm, an obstetrician reviewed Miss O. They documented her history and investigations of that date. They noted a plan to induce labour at 39 weeks owing to the risk factors of age and diminished or altered foetal movements.
38. In this case, we consider the Trust acted in line with NHSE guidelines by offering Miss O an IOL on 6 October. The records indicate she reported RFM and was concerned enough to attend triage on two occasions. By this time, she was over 38+6 weeks.
39. As above, we could not see any evidence Miss O requested a caesarean section on 6 and 18 October. We therefore cannot say the Trust did anything wrong on this issue, as there is no documentation that a caesarean section was requested and considered.
40. The records do show Miss O requested a caesarean section overnight on 13 October. At 10.45pm, an obstetrician reviewed Miss O and her CTGs following removal of a propess. The obstetrician noted the CTG was normal, though Miss O appeared anxious and unhappy with foetal movements.
41. The records indicate Miss O requested an emergency caesarean section. In response, the obstetrician explained they would not do one that night but would keep the propess out and review Miss O in the morning to discuss further management.
42. At 10.41am on 14 October, an obstetrician reviewed Miss O. They documented she needed a second propess. They planned to perform a repeat CTG, vaginal examination, and continue with IOL.
43. From advice sought we understand that unless there is an emergency, a caesarean section would not be performed overnight. In this case, there is no medical indication for one on 13 October. Our adviser told us the CTGs taken at that time indicate baby was fine, and Miss O was in the middle of the IOL process. Overall, our adviser told us there is no medical indication for a caesarean section on any of the dates mentioned.
44. Considering this, we cannot see an indication the Trust did anything wrong by declining to perform a caesarean section on 13 October. At the time of Miss O asking, it was overnight but was not an emergency. This is because CTGs indicate baby was well and Miss O’s observations were normal.
45. We hope Miss O is reassured that the Trust acted in line with relevant guidelines in offering her IOL. The evidence indicates there was no medical indication for an emergency caesarean section on 6, 13, and 18 October. We therefore cannot say the Trust has done anything wrong on this issue.
Delay in breaking water and inducing labour
46. Miss O says the Trust delayed breaking her water and inducing her labour between 12 and 20 October 2022. As a result, she says she felt stressed and anxious.
47. We can only imagine how scary it must have been for Miss O to go through an emergency caesarean section in the early hours of 20 October. This is especially so after five days in the IOL process. As the evidence indicates, she understandably grew increasing distressed and frustrated with the wait for a bed.
48. In its complaint response, the Trust explained the delays Miss O experienced were due to high clinical acuity and staffing shortages on the labour ward. We asked our adviser if there were any opportunities for the Trust to induce labour earlier.
49. Our adviser told us staffing shortages within labour wards is a common issue across Trusts nationwide. They told us NHSE guidelines are most relevant for this issue. NHSE guidelines aim to reduce perinatal mortality. As a result, Trusts are seeing more women on labour wards as a natural consequence of increased rates of induction.
50. Our adviser told us NICE guidelines are also relevant. These guidelines outline how clinicians/midwives should interpret CTGs. A baseline of 100 to 160bpm, for example, with none or early decelerations is considered normal or reassuring. Midwifes should continue CTG and normal care.
51. On 12 October, the Trust admitted Miss O for IOL. Due to delays experienced on the labour ward, an obstetrician did not induce labour until around 12.30am on 13 October.
52. The records indicate midwives performed regular CTGs, the majority of which were normal, and observations between 12 and 19 October.
53. An abnormal CTG (with two decels recorded) is noted at 6.40pm on 13 October. At 8.10pm, a midwife bleeped the doctor to review. Staff recommenced the CTG following removal of the first propess pessary at 8.30pm. The second CTG is noted to be normal. NICE guidelines recommend continuing normal care.
54. Miss O reported irregular cramps, palpitations, and reduced movements in the afternoon of 14 October. The records indicate she had started contracting. A midwife commenced a CTG to check baby and bleeped a doctor to review. Miss O’s CTG was discussed with a senior registrar and consultant. They documented a plan to transfer her to the labour ward once it could accommodate.
55. Overnight on 15 October, a midwife noted a lightly bloodstained show on Miss O’s pad. Miss O reported further PV bleeding at 6.25am. Staff continued to carry out observations and CTGs, which were normal. As above, NICE guidelines recommend continuing normal care.
56. At 12.26pm, an obstetrician reviewed Miss O. They planned to continue four hourly observations, twice daily CTGs, and to aim for an ARM on the delivery suite. On examination, they noted Miss O was 2cm dilated. The records indicate the second propess pessary had come out overnight.
57. The medical records between 16 and 19 October document Miss O was still waiting an ARM on the delivery suite, which ‘depends on staffing and bed availability.’ The records indicate Miss O often became upset and frustrated at the wait. Staff continued to offer reassurance via CTGs and explained the wait was due to staffing and capacity.
58. On 18 October, a midwife also apologised for a delay in giving Miss O codeine. The notes document ‘apologies given for delay due to obstetric emergency on ward and now second midwife has been pulled to LW at 10.30pm – leaving me the only midwife on the ward, currently over capacity, apologies given for any delay in care due to this.’
59. At 10.50pm on 19 October, a shift coordinator called for Miss O to come to the labour ward. Miss O was transferred at 11.45pm. The records indicate midwives planned to commence ARM straight away.
60. A CTG was restarted at 12.04am on 20 October. A midwife took Miss O’s observations. An anaesthetist administered an epidural at 1.45am.
61. At 1.54am and 2.02am, the CTG showed variable decelerations. The midwife discussed with senior staff. At 2.12am, the midwife performed ARM. The records document observed drops in foetal heart rate during the ARM. The midwife informed the obstetrics team. NICE guidelines say these CTG results indicate a need for urgent intervention. Midwives should urgently seek obstetric help and make preparations for urgent birth.
62. During our discussion, our adviser told us the CTG which was commenced following the epidural administration demonstrated increasing frequency of deep and wide decelerations of the foetal heart rate. There was no sign of these improving. Our adviser stated, prior to delivery, there was evidence of the start of a longer period of abnormally low foetal heart rate (bradycardia).
63. During this time, retrospective notes document an obstetrician reviewed Miss O. The CTG showed recurrent broad decels and the obstetrician made a decision for a category one caesarean section at 2.19am. This is in line with NICE guidelines.
64. From advice sought we understand it was appropriate to deliver the baby urgently by caesarean section. At delivery, they noted the baby’s cord blood confirmed delivery was indicated and had therefore been the correct course of action.
65. Retrospective midwife notes document Miss O entered theatre at 2.28am and her baby was delivered at 2.41am. Miss O’s son was born with the cord around his neck and right foot. He appeared floppy with a heart rate of less than 100bpm and was taken to resus. Staff returned him to his parents at 3.07am.
66. At 3.15am, Miss O was transferred to recovery.
67. Overall, the records indicate there was a five day delay between the commencement of induction of Miss O’s labour and her being transferred to the labour ward for ARM. There are several instances within the records which indicate the labour ward was at capacity and was experiencing staffing issues. Specifically, each day between 16 and 19 October document apologies given to Miss O and explanations about the wait.
68. Our adviser stated it is appropriate for staff not to take on additional work (i.e., inducing more women) if the labour ward is busy to avoid having multiple simultaneous emergencies. It would be up to those managing the labour ward as to how many inductions it can accommodate at one time, based on the other activity occurring during that time.
69. Our adviser acknowledged it was an exceptionally long delay of five days. However, they stated they would not be able to identify or say whether there are any earlier opportunities to break Miss O’s waters and commence labour without having been on the labour ward at the time.
70. We appreciate this may be frustrating to Miss O. To reassure her, from the advice sought, we cannot say the delay led to her requiring an emergency caesarean section. It is understandable that she would have been frustrated in the circumstances. Unfortunately, our adviser could not offer a prediction as to what would have happened had labour taken place earlier.
71. In summary, we cannot say that the Trust has done anything wrong regarding the delays in breaking Miss O’s waters and inducing labour. The evidence indicates the labour ward, and indeed the ward Miss O was on at the time, faced staffing and capacity issues. The Trust have explained this in its complaint response.
72. We consider the records indicate Miss O’s CTGs between 12 and 19 October were normal. It would not be appropriate or in line with NICE guidelines to intervene, as they recommend continuing care as normal. As per the discussion with our adviser, it is reasonable for staff not to take on additional inductions if they do not have the capacity to do so.
73. Overall, there are no indications the Trust has done anything wrong on this matter. We hope our explanation provides reassurance to Miss O.
Delay in taking observations
74. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
75. Miss O says the Trust delayed taking her observations between 12 and 14 October 2022. As a result, she says she felt stressed, not listened to, and dismissed. She says her vaginal pessary had to be redone on 13 October.
76. We were very sorry to hear Miss O felt this way and that she experienced delays in starting her IOL process. To address Miss O’s concerns on this matter, we reviewed her relevant medical records and the Trust’s complaint file.
77. On 12 October, the Trust admitted Miss O for IOL. The records indicate there was a wait for her to be seen on arrival. At 4.15pm, a midwife bleeped the doctor. They commenced a CTG at 5.04pm, which was completed as normal at 5.54pm.
78. At 6.46pm, an obstetrician reviewed Miss O. A midwife repeated observations at 9pm. They documented Miss O felt frustrated due to the wait. They bleeped the doctor twice.
79. At 11.28pm, a doctor performed an ultrasound scan to identify baby’s position. At 12.30am on 13 October, an obstetrician induced labour with a propess pessary.
80. In its complaint response, the Trust apologised for the delay in taking Miss O’s observations and commencing her IOL. We consider this to be an indication of a failing. The Trust explained the delays were due to emergencies on its labour ward.
81. Our NHS complaint standards say when something has gone wrong, organisations should identify suitable and appropriate ways to put things right for people. This should include meaningful apologies and explanations that openly reflect the impact on the people concerned.
82. The Trust has apologised and explained the reasons for the delays on 12 October. As per our NHS complaint standards, we consider these actions to be proportionate to the injustice faced. According to the records, Miss O experienced a delay of a few hours.
83. Miss O told us one of her desired outcomes would be an apology. As the Trust has already offered this, we consider it has taken the appropriate actions regarding this issue.
84. Miss O also told us one of her desired outcomes would be a financial remedy. We use our severity of injustice scale (SOI) to make consistent, fair and transparent recommendations. The scale has six bands ranging from level one injustices, including worry, pain and annoyance of relatively short durations, up to level six, which are life changing events often with profound consequences.
85. Our SOI scale puts Miss O’s injustice at level one. A level one injustice typically arises from a single incidence of maladministration or service failure, where the effect on the individual is of short duration, and where there are no other adverse effects or wider ongoing impact.
86. This is the case for Miss O. We would not recommend a financial remedy for a level one injustice and generally consider an apology to be an appropriate remedy.
87. We are satisfied the Trust has taken appropriate action to put things right. We do not consider there are any indications it needs to do more to remedy this part of the complaint.
Delay in administering pain relief
88. Miss O says the Trust delayed administering her with pain relief on 19 and 25 October 2022. As a result, she says she experienced debilitating pain for hours. She says she felt stressed, trapped, and like she was not being taken care of.
89. We were very sorry to hear Miss O experienced pain and felt dismissed. It must have been a scary time for her, especially as this was the birth of her first child. To address her concerns, we reviewed her relevant medical records and the complaint file.
90. The records indicate at 12.20am on 19 October, Miss O requested oral morphine. The midwife explained this was a controlled drug and required a second midwife. They explained there was a current emergency situation regarding staffing and capacity. The records indicate oral morphine was administered at 12.54am as a neonatal nurse was available to oversee dosage. Two midwives checked on Miss O at 1.30am and 2.05am.
91. The records indicate Miss O reported discomfort at 8.43am on 25 October. Analgesia was given as prescribed. We could not see any evidence of a delay in giving pain relief.
92. In its complaint response, the Trust apologised Miss O was in pain for longer than expected. We consider this to be an indication of a failing. The Trust explained there was a high level of unwell and emergency patients at the time on the labour ward. It also explained morphine, as a controlled drug, requires two qualified staff to check and sign.
93. We consider the Trust’s apology and explanation to be in line with our NHS complaint standards. This is because the records indicate Miss O was in pain due to the delays for under an hour on 19 October.
94. Miss O told us her desired outcomes would be for an apology and a financial remedy. We can see the Trust has apologised through the complaint response. We would not consider a financial remedy appropriate on this matter, as the impact suffered sits at a level one criteria highlighted above.
95. We consider the Trust’s actions appropriate for the injustice caused. We do not consider there are any indications it needs to do more to remedy this part of the complaint.
96. We were sorry to hear about Miss O’s birth experience and the subsequent distress she has suffered. We thank her for bringing her complaint to our attention.
97. We have carefully considered the evidence provided. Based on this, we have seen some indication the Trust delayed taking observations and administering pain relief. Where this was the case, the Trust has apologised. We consider this is a reasonable action to resolve the concerns.
98. We have seen no indication that anything went wrong regarding the decisions not to perform an ultrasound scan and a caesarean section. We also consider the Trust did not do anything wrong regarding the timeframe of Miss O’s IOL process, though we acknowledge this must have been frustrating and distressing for her at the time.
99. Overall, we have decided not to take any further action on Miss O’s complaint.