12. 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.
Treatment 13. Miss C complains the Trust did not administer her with antibiotics before her baby was born on 2 September 2024. She says she tested positive for GBS infection earlier in her pregnancy and knew she would need antibiotics during labour to prevent it being passed on to her baby. We are sorry to hear she did not feel listened to. It is clear from what she has told us that this caused her further anxiety at an already distressing time.
14. NICE guidelines on neonatal infection say offer antibiotics during labour to women who have GBS infection during the current pregnancy. It goes on to say give the first dose of antibiotics as soon as possible after labour starts and continue until the birth of the baby.
15. RCOG states that women who are known GBS infection carriers should be offered immediate antibiotics and induction of labour as soon as reasonably possible after waters have broken after 37 weeks of pregnancy.
16. Miss C’s records show the Trust confirmed she tested positive for GBS infection in week 23 of her pregnancy. On 29 August the Trust documented Miss C would begin antibiotics during labour.
17. She attended the Trust on 2 September at 5.05am after her water broke. We can see it prescribed antibiotics at 5.17am. However, it appears there was an issue with the dose on the prescription and the Trust discontinued it 6.28am. It provided a further prescription for antibiotics at 6.30am. Miss C’s baby was born just after 12pm.
18. Based on the records we received, although the Trust prescribed antibiotics for Miss C, it does not appear it administered these to her between the time she presented to it and when her baby was born. Therefore, it appears it did not follow NICE and RCOG guidelines to give the first dose of antibiotics as soon as possible after labour begins and continue until the birth of the baby.
19. There is no evidence to suggest she passed GBS infection on to her baby. Therefore, we cannot say this had a clinical impact on Miss C or her baby. However, we can see how this would have led to the anxiety Miss C told us about, as she says she asked it for antibiotics several times but was ignored. We are also sorry to hear her experience has impacted her mental health and she is scared to have more children.
20. We contacted the Trust to ask if it would be willing to take action to address the complaint and impact on Miss C. We explained the outcomes Miss C told us she was seeking from bringing her complaint to the Ombudsman.
21. Our Principles say where something has gone wrong or poor service has led to an injustice or hardship, the organisation responsible should take steps to provide an appropriate and proportionate remedy. When impact cannot be put right, we consider if compensation would address this.
22. Miss C is seeking service improvements and a financial remedy. She told us she feels her experience aligns mostly to level two or three on our severity of injustice scale which is a maximum of £1200.
23. The Trust has explained it has already taken action to prevent the same thing from happening again. It has provided us with an action plan which outlines how it plans transition to a comprehensive digital system which includes medication charts and improvement work relating to listening to birthing people and their families. It has also agreed to pay her £1200.
24. We are satisfied that the agreed actions, address what went wrong in Miss C’s care and are in line with our Principles. It also achieves the outcomes Miss C told us she wanted, therefore resolving this complaint. We hope this will provide Miss C with some reassurance the Trust has taken her complaint seriously.
Discharge and communication 25. Miss C says the Trust did not listen to her concerns about jaundice before and shortly after her and her baby were discharged on 3 September. Understandably, Miss C is concerned about the Trust’s decision to discharge her and her baby despite her concerns, as they were readmitted to the Trust on 5 September. We are sorry to hear this impacted their first few weeks together.
26. NICE guidelines on post-natal care says at each postnatal contact, ask parents if they have any concerns about their baby's general wellbeing, feeding or development. Review the history and assess the baby's health, including physical inspection and observation. If there are any concerns, take appropriate further action.
27. It goes on to say carry out a complete examination of the baby within 72 hours of the birth. This should include checking the baby's appearance, including colour, breathing, behaviour, activity and posture.
28. NICE guidelines on jaundice in newborn babies says measure and record the bilirubin level urgently in all babies more than 24 hours old with suspected or obvious jaundice.
29. The records show the Trust assessed Miss C’s baby on 3 September. It noted the baby was pink, alert and all other observations were normal. It discharged them both on the same day.
30. The Trust visited Miss C at home on 4 September and examined her baby. It noted the baby was alert and handled well. It also noted the baby had jaundice in the eyes, face and trunk. It carried out a blood test to assess for the severity of the jaundice, which showed moderate levels, and it asked Miss C to return to hospital with her baby on 5 September for treatment.
31. Based on the records we have seen, the Trust did not note Miss C had any concerns her baby had jaundice before or shortly after she was discharged.
32. Our adviser explains based on the records seen, there is no indication the Trust missed an opportunity to diagnose Miss C’s baby with jaundice earlier than 5 September. Therefore, it appears the Trust followed NICE guidelines on both post-natal care and jaundice in newborn babies when it discharged her and her baby on 3 September and later re-admitted them on 5 September. We can see the Trust assessed Miss C’s baby before it discharged them and did not note any symptoms of jaundice.
33. We can also see it carried out an examination at her home within 72 hours of the birth and carried out a blood test when it suspected jaundice. Therefore, it appears it identified and diagnosed jaundice as soon as symptoms presented.
34. It is clear from what Miss C has told us, she feels the Trust ignored her concerns about jaundice which we are sorry to hear. We do not underestimate how difficult it must have been to relive these events and explain her complaint to us. We are grateful for the time and effort she has taken to do this.
35. Based on the information we have seen it is clear Miss C’s version of events differs to the information recorded by the Trust. It would be difficult for us to prove Miss C’s claims as there is no objective evidence available to support her version of events. Therefore, it would be unlikely that we would be able to provide her with a further explanation of what happened other than what we have explained above.
36. Overall, based on the evidence we have seen, we do not think an investigation would lead to a satisfactory outcome for Miss C as there does not appear to be any additional evidence for us to draw upon and consider further. We will therefore not take further action on this complaint.
37. We understand Miss C’s experience has caused her great distress and we are sorry to hear about the lasting impact she said her experience has had on her. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance the Trust has taken action to address what went wrong.