North Middlesex University Hospital NHS Trust

3. Miss X complains about the following aspects of the care and treatment provided by the Trust from October 2023 to April 2024:

• Trust staff were dishonest about discussions they had with her and inaccurately recorded information and notes of appointments with her • The Trust failed to conduct further tests and investigations or provide relevant information or support when she reported concerning symptoms, including fainting and dizziness, reduced foetal movements, and signs of infection • Trust staff failed to adequately communicate with her throughout her pregnancy, and since the death of her daughter.

4. Miss X says the inadequate care and treatment provided by the Trust led to the death of her daughter, which has left her traumatised and distressed.

5. As a result of this complaint, Miss X is seeking an apology from the Trust for the avoidable death of her daughter, as well as the distress caused to her by her treatment throughout her pregnancy, and service improvements to prevent others facing the same treatment. Miss X would also like a financial remedy to reflect the pain and distress caused by the death of her daughter.

6. Miss X has expressed concerns regarding the standard of care she received from the Trust during her pregnancy. She describes a recurring pattern of errors, insufficient information, dishonesty, and poor communication throughout her maternity experience.

7. During her pregnancy, Miss X says she experienced frequent episodes of dizziness and fainting, which persisted for approximately two months and ultimately led to a head injury following a fall. She tells us that, although she informed Trust staff of these symptoms, it provided no advice or support.

8. Miss X says that several inaccuracies and procedural issues occurred during her care. She says staff recorded her ethnicity incorrectly in official documentation. She also says her care was transferred to another team without her knowledge or consent. In addition, she says staff documented having discussed her birth plan and foetal movements with her, despite these conversations never taking place.

9. At her final antenatal appointment, Miss X says she raised concerns about a noticeable reduction in foetal movements over the previous two days, alongside symptoms that indicated a urinary tract infection. Although tests were conducted to investigate these symptoms, she tells us these tests were lost and no treatment or antibiotics were provided.

10. At approximately 39 weeks into her pregnancy, Miss X experienced spontaneous rupture of membranes (SROM). This is when foetal membranes naturally break before labour begins, more commonly referred to as ‘water breaking’. She contacted the triage service and subsequently attended the hospital. Miss X says that during this visit she was not asked about her baby’s movements and felt that staff did not take her concerns seriously. Miss X’s daughter was later sadly confirmed to have died, and Miss X then gave birth to her.

11. A post-mortem referral form initially listed a ‘foetus with a likely chromosomal abnormality’ as the probable cause of death. However, post-mortem findings later concluded that the baby had been otherwise healthy and identified an untreated infection, associated with or following SROM before labour, a suspected umbilical cord compression, and cord accident as the causes of death.

12. Miss X was informed that she did not meet the criteria for a Maternity and Newborn Safety Investigations (MNSI) inquiry after her daughter had died. She says she had to independently ensure an MNSI investigation was conducted.

15. The ‘Health Service Commissioners Act 1993’ says we cannot investigate a complaint if the person involved has (or had) the option to take legal action, unless we think pursuing legal action is (or was) unreasonable in the circumstances. Simply put, if someone has a legal route available to achieve the outcomes they are looking for, and if it is reasonable for them to pursue that route, we are not able to look at the complaint further.

16. To understand Miss X’s situation and desired outcomes, and whether it would be reasonable for her to explore legal action, we reviewed the documents she submitted to us and discussed this with her. Our role is not to assess whether legal action would be successful but rather whether it is a reasonable option to consider.

17. Miss X has raised several concerns about the clinical care provided by Trust, explaining that she is concerned that it made mistakes which contributed to the death of her daughter. As such, it appears that Miss X may have legal recourse through the courts with a clinical negligence claim.

18. We have therefore considered whether legal action could help her achieve the outcomes she is seeking, and whether it is reasonable for her to take that route.

19. Miss X has indicated that she is seeking financial compensation for the avoidable death of her daughter. Based on this, we can see the courts may be better placed to achieve this financial outcome.

20. We also considered possible barriers to pursuing legal action and any reasons why it might not be reasonable for Miss X to take legal action. Miss X confirmed she has appointed a solicitor who has already accepted the case. Therefore, it does not appear that there are any barriers to her pursuing that action because she is already doing so.

21. With the above in mind, we can see Miss X has a legal route available to her and it would be reasonable for her to pursue it to achieve the financial remedy she seeks. There are time limits for filing a legal claim (usually three years), and so we recommend Miss X discusses her case with her solicitor as soon as she is able.

22. In addition to financial compensation, Miss X also seeks an apology and service improvements. This is not something the courts are likely to directly achieve for her, although they may be implemented as a byproduct of any legal action.

23. This means that, if Miss X pursues legal action for the financial remedy she seeks, she can return to us after legal action is complete for any outcomes that the courts could not achieve for her, including an apology for the impact of any errors in the care and treatment provided, as well as service improvements. It is also open to Miss X to return to us if she explores legal action and it becomes clear that it is no longer reasonable for her to pursue that route.

24. If Miss X does return to us in future, it is important that she does so promptly because we would need to consider our own one-year time limit, in line with the ‘Health Service Commissioners Act 1993’. We can set this limit to one side where there is good reason to do so. Any delays in returning to us may affect our ability to set the limit aside, so we encourage her to contact us as soon as she is able.

25. We understand that this is a difficult time for Miss X, and we would like to thank her for sharing her loss and experience following her daughter's death so openly. We appreciate the openness she has shown in describing the events and her concerns. We hope this statement clearly sets out how we thought about what she told us and how we reached our decision in this case.

1. We have carefully considered Miss X’s complaint about North Middlesex University Hospital NHS Trust (the Trust). Miss X complained about aspects of the care and treatment the Trust provided to her throughout her pregnancy, which she says led to the death of her daughter. We were very sorry to hear about the loss of Miss X’s daughter and the impact this has had, and continues to have, on her.

2. Having carefully thought about what Miss X told us we have decided to take no further action. This is because we can see Miss X has a legal route available to her to achieve the financial remedy she seeks and we consider it is reasonable for her to explore that route, because she is already in the process of doing so. We explain further below.