20. 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. Having done so we cannot link the events complained about with the negative impact Mrs O has claimed. We explain the reasons for our decision below.
Blood monitoring and medication
21. Mrs O says her blood tests and medication were either not changed, changed too soon or adjusted by incorrect doses resulting in her TSH levels fluctuating
22. Mrs O says she also was not aware of all the blood results. Not all of them were showing on her badger notes.
23. The Trust apologised and said it would take action in improving communication surrounding blood tests and also how to help patients problem solve issues with the badger notes application.
24. NICE guidelines state thyroxine (thyroid hormone) should be increased as soon as pregnancy is confirmed. Typically, by 25–50 mcg followed by thyroid function tests (TFTs) every four to six weeks. This is supported by the BTF guidance.
25. BTF guidance recommends that TSH should be lower than 2.5 in the first three months of pregnancy, and less than 3 in the second three months of pregnancy, with FT4 (free thyroxine) ideally between 13 and 18, which is higher than in people who are not pregnant.
26. Our endocrinology adviser said that from the Trust records, it is unclear if Mrs O’s thyroxine was immediately increased by her GP upon telling them she was pregnant. We can see she was on 125 mcg of thyroxine in January 2024.
27. Mrs O had blood results on 10 April 2024. Mrs O’s TSH was elevated at 19.35 and FT4 was 11.5.
28. Our adviser explained this is known as subclinical hypothyroidism. Subclinical hypothyroidism is when your TSH levels are higher than normal, but your thyroid hormone levels are still within the normal range. ATA research involving 18 studies and 3,995 participants found limited evidence linking subclinical hypothyroidism (SCH) to poor pregnancy outcomes.
29. Mrs O’s dose of thyroxine was increased to 150 mcg on 12 April, within two days of the result, this is considered a prompt and appropriate response in line with the BTF guidance.
30. On 18 April the Trust informed Mrs O, it would not increase the dose again as it had only just been increased. The Trust arranged a blood test for in three weeks’ time on 3 May.
31. This would make the TSH monitoring in line with monitoring every four to six weeks.
32. Mrs O was unable to attend a planned blood test on 3 May as this was not convenient for her and so an earlier appointment was arranged on 29 April. It would have been possible for the Trust to check if they could do the blood test later than 3 May as that would have still fell within guidelines until 17 May.
33. From the records it is clear Mrs O was informed that this would be earlier than normal and may affect results. This is due to how long thyroxine takes to act on the body.
34. The 29 April results showed TSH at 2.90 and FT4 at 14.5, placing her thyroid status slightly above the ideal first trimester reference range.
35. At approximately eight weeks pregnant, the decision was made to increase her dose of thyroxine to 175 mcg on 8 May, nine days after the results above.
36. The BTF guidance says dose changes should be done within a few days to a week. Nine days is just outside of this timeframe. This is considered appropriate if the thyroid levels are not causing any symptoms. There are no symptoms documented in the records.
37. A further test on 31 May showed TSH was low at 0.09 and FT4 at 17.9. These results show a drifting to what is known as hyperthyroidism. This can be harmful if not managed properly. In response, Mrs O’s dose was reduced on 5 June, to alternate between 150 mcg and 175 mcg daily.
38. This occurred five days after the test result. This timing was appropriate, and the action taken addressed potential over-replacement promptly.
39. Our endocrinologist adviser informed us that over correction is likely initially, and the only way to get the dosage right is to monitor and then make corrections to the dose to try and manage the levels into the appropriate ranges.
40. Overall, the healthcare team responded appropriately once the issues were identified.
41. Although an endocrinologist may be made aware of a patient being pregnant, they may not necessarily see the patient. They may, just write a letter to the GP informing them of the standard practice of increasing thyroxine and blood monitoring every four to six weeks.
42. The healthcare team at the Trust completed blood tests appropriately, monitored Mrs O as it should have, and made dosage changes when it needed to. This is in line with the NICE and BTF guidelines, highlighted above. They do not indicate anything seriously went wrong.
45. We understand how deeply distressing this experience has been for Mrs O. We recognise the emotional impact of what she has gone through is still significant.
Symptoms during pregnancy
47. During the local resolution meeting on 18 November 2024, Mrs O shared that she had raised concerns with her midwife about experiencing ‘all the symptoms of a miscarriage minus stomach cramps’. Mrs O questions whether travelling while experiencing symptoms, could have contributed to the miscarriage.
48. Mrs O felt the Trust should have taken her symptoms more seriously.
49. Mrs O believes that if her concerns had been more thoroughly considered, the midwife might have advised against her planned.
51. In response, the Trust acknowledged Mrs O’s concerns and confirmed that her feedback would be discussed among the team to improve how complications in pregnancy are addressed.
52. The Trust emphasised that patient experience is vital and that her account would help inform future practice.
53. Within the medical records, the only symptom recorded during this time was backache.
54. Our gynaecology adviser states that backache alone is a common and non-specific symptom in pregnancy. It is not typically considered a direct indicator of miscarriage unless accompanied by vaginal bleeding or cramping.
56. The midwife assessed Mrs O when she saw her on 3 June 2024date and advised her on what to do if her symptoms worsened.
57. The Early Pregnancy Unit Guideline provided by the Trust supports this approach, stating that a second scan is not routinely offered unless there is abdominal pain or bleeding. Based on the records, the Trust followed this protocol appropriately.
58. Our adviser confirmed that flying during early pregnancy including at 12 weeks is generally considered safe for most women.
59. Airlines typically permit travel up to 28–36 weeks, depending on their policies.
63. First-trimester miscarriages are unfortunately common and often occur due to factors unrelated to travel. RCOG public guidance states that flying is not harmful in uncomplicated pregnancies and does not increase the risk of miscarriage.
65. RCOG scientific impact paper reinforces that there is no direct link between air travel and pregnancy complications, though it advises caution in later stages of pregnancy.
66. From what we have seen the Trust followed its own guidelines as well as further evidential guidance available. Therefore, we do not see that there are any indications of failings.
67. We hope this information provides reassurance to Mrs O, even though we recognise the experience remains deeply upsetting.
Scans
68. At 12 weeks pregnant, Mrs O did not hear her baby’s heartbeat during a scan on 16 May 2024. The sonographer said there was ’not enough energy’. Mrs O and her partner felt the sonographer lacked care and was more focused on selling a photo than checking the baby properly.
69. Mrs O believes better care could have identified early signs of miscarriage and prevented her from carrying a dead baby for three weeks, which she found distressing and unsafe. The Trust explained that using a doppler to check the heartbeat is not recommended, as it may affect the baby’s tissues.
70. The Trust says it has fed back what Mrs O has said about her experience of the scan, so the team can improve and patients in future do not feel how Mrs O and her partner did during their scan.
71. BMUS 2021 guidelines state that during the 12-week scan it is important to visually assess the baby's development. This includes measuring the crown-rump length (CRL, the measurement from the top of the head to the bottom) and checking for structural irregularities.
72. Listening to the heartbeat is typically avoided unless there is a specific clinical reason to do so. While handheld dopplers can sometimes detect a heartbeat from around 12 weeks, this is more commonly done from 14 weeks onward, and even then, only when necessary.
73. This is confirmed by NHS scans during pregnancy and information on twelve week scan web pages.
74. Our sonography adviser reviewed the scan images and the scan report.
75. The scan showed normal foetal development, and there was no medical reason to listen to the heartbeat at that time. The CRL and nuchal translucency (NT) images were of high quality and showed no concerns.
76. Our adviser explained there are various doppler techniques. These are colour, power and spectral. Doppler techniques use the doppler effect to measure the velocity and direction of blood flow.
77. There is also M-Mode and B-Mode which are used primarily for structural imaging rather than flow. The B-mode is the standard 2D grayscale image in ultrasound. The M-mode captures motion of structures over time along a single scan line.
78. B-Mode was used during the scan for the structural imaging of the baby. Then power doppler was used appropriately to assess the abdominal wall, umbilical insertion (at what point the umbilical cord attaches to the placenta), and uterine artery. To check this using power doppler, would not impact the foetus directly.
79. Current professional guidelines caution against the routine use of doppler in the first trimester. BMUS 2009 guidance, EFSUMB, and ISUOG all advise that doppler techniques such as spectral doppler and colour flow imaging should only be used for specific indications like screening for trisomy (indicating such conditions as Down Syndrome) or cardiac anomalies, and only by specially trained professionals.
80. The Trust’s policy recommends that sonographers confirm the foetal heartbeat visually by showing parents the pulsating image, rather than using doppler audio.
81. According to its protocol, factors that can raise concern for miscarriage include an unusually small gestational sac (GS) relative to CRL, oligohydramnios (to little amniotic fluid), a foetal heart rate under 90 bpm (bradycardia), or a discrepancy of over ten days between scan dates and menstrual history.
82. None of these indicators were present in Mrs O’s scan.
83. Subchorionic hematoma (a condition in pregnancy where blood collects between the uterine wall and the chorionic membrane, which surrounds the baby’s amniotic sac) is another potential risk factor to miscarriage.
84. This was not mentioned in the report. Its absence suggests no obvious signs were detected at the time.
85. The scan showed fetal movement and normal development, and no concerns were raised. Unfortunately, a miscarriage occurred after this scan, but at the time, there was no clinical reason to suspect a problem.
86. The evidence indicates the baby died after this date, due to the size recorded of the baby on the scan, and the size of the baby after the birth.
87. We recognise it was distressing for Mrs O to have been carrying the baby for three weeks after it died. Sadly, there is nothing that could have been done to determine this sooner.
88. This is known as a missed or silent miscarriage. It happens when the baby has died, but the body has not yet recognized the loss, so there are often no clear signs or symptoms. This can make the experience even more difficult and confusing for those going through it.
89. We want to provide our deepest condolences for what Mrs O experienced. No matter the levels of statistics for miscarriage, it is still something awful for anyone to go through. We hope by sharing our explanations Mrs O feels reassured that it could not have been recognised any earlier.
90. We recognise this has been a difficult time for Mrs O and understand how the events she has complained about have affected her. We have not seen that anything went wrong with the service provided by the Trust and therefore we are taking no further action on the complaint. We hope our decision provides some reassurance to Mrs O that the Trust did treat her in line with appropriate standards and guidelines.