Miss F’s antenatal care
Booking appointment on 14 May 2018 (eight weeks)
25. Miss F and Mr J complain the Trust did not class her pregnancy as high risk although she had pre-eclampsia with her first child. They believe the Trust would have monitored her more closely and given different treatment had it done this. They think this could have saved Baby R.
26. Miss F’s records show the midwife at the booking appointment did not class her pregnancy as high risk but did request a consultant appointment. They made the referral because she had pre-eclampsia before, was known to be GBS positive and had surgery for ovarian cysts before. After the referral was made, some advice was given but another appointment was not made.
27. It is the role of midwives to decide the risk grading of a pregnancy and whether women need an early obstetrics review (a review by a doctor specialising in childbirth and delivery). The NICE antenatal care CKS says midwives should assess the risk factors for pre-eclampsia at the booking appointment. It also says midwives should refer women at risk of pre-eclampsia for consultant-led care.
28. The NICE hypertension CKS also says midwives should consider women with a history of pre-eclampsia during a previous pregnancy to be at high risk of developing it again. It goes on to say midwives should refer these women for ‘consultant-led care at booking for specialist input to assess and manage the obstetric risk’.
29. We consider it would have been in keeping with this NICE guidance for the midwife to have recorded Miss F’s pregnancy as high risk as well as to refer her to obstetrics. A consultant should have then seen Miss F and considered her obstetric history and risk in more detail. It is a failing that this did not happen.
30. We have carefully considered whether this failing had any impact on Miss F or Baby R. We know Miss F did not go on to develop pre-eclampsia, so it did not have any direct impact. But we will consider the impact of this failing later in our report.
31. We note the Trust’s hypertension risk assessment does not list having pre-eclampsia before as a risk factor. The Trust’s RCA report also suggests a referral to a consultant is not normal practice when a woman is at high risk of developing pre-eclampsia. This is not in line with the NICE guidance and may explain the issues we have seen here.
Visit on 12 September 2018 (26 weeks)
32. Miss F says she went to see her GP with period-like pain and blood-stained vaginal discharge. The GP took a swab and tried to listen to Baby R’s heart rate, but their equipment was not working. The GP phoned the Trust and advised her to go there so a midwife could check Baby R’s heart rate instead.
33. The midwife at the Trust checked Baby R’s heart rate which was normal and noted pink/brown vaginal discharge. They say the midwife told them she was in early labour.
Miss F and Mr J say by this point it was becoming normal for them to complain of vaginal discharge and midwives to dismiss it but not explain what it was. They say this left them feeling concerned and confused.
34. Miss F’s pain and vaginal discharge could have indicated an infection. The NICE antenatal care CKS says vaginal discharge is common in pregnancy but itching, soreness, an unpleasant smell, or pain passing urine may indicate an infection. We can see the GP took a swab to test for infection in line with the NICE antenatal care CKS. This means the midwife did not need to take any further action.
35. Miss F’s pain could have indicated she was in preterm labour (labour before 37 weeks). NICE CG190 says clinicians should assess women in possible labour to see if they are in labour. It says clinicians should take both the woman and unborn baby’s observations and auscultate (listen to) the foetal heart (baby’s heart). It also says a vaginal examination may be helpful after a period of assessment.
36. In line with NICE CG190, the midwife should have taken steps to investigate whether Miss F was in preterm labour. It is likely they did not do this as the GP only referred her for a foetal heart check. This was a failing but we do not think it had any impact on Miss F as she did not go into preterm labour.
37. Miss F’s pink/brown vaginal discharge could have indicated antepartum haemorrhage which is bleeding that happens from 24 weeks of pregnancy. It complicates three to five percent of pregnancies and is a leading cause of perinatal and maternal mortality (where the mother and/or baby dies).
38. Green-top guideline 63 says GPs and midwifery-led units should assess pregnant women who present with bleeding and move them to a hospital maternity unit with facilities for resuscitation and performing emergency operative delivery. It says a multidisciplinary team (a team made up of health professionals from different areas) including obstetric staff should then provide clinical assessment to women who have bleeding.
39. Green-top guideline 63 also says women who have bleeding should have investigations to check the extent and impact of the bleeding. It says these investigations will depend on the amount of bleeding but women with ongoing bleeding or bleeding heavier than spotting should stay in hospital until the bleeding has stopped.
40. The midwife’s notes say, ‘pad seen? pink loss/brown’ which suggests they observed possible bleeding. In line with green-top guideline 63, they should have done an examination to investigate this further and referred Miss F to obstetrics so a doctor could consider whether she had a possible bleed. This did not happen and it is a failing.
41. The Trust’s RCA report says pink/brown loss is not normal and suggests bleeding. It also says there was a discussion with staff about whether Miss F needed an examination and review by an obstetrician. These comments support our findings. We consider this failing later in our report.
Telephone call and visit on 20 September 2018 (27+1 weeks)
42. Miss F and Mr J say she woke up and was aware Baby R’s movements had stopped so she phoned the Trust in a panic. The midwife advised her to attend, which they did, and Baby R was found to be active with a normal heart rate. They say they were worried but, at the time, left feeling reassured.
43. This was the first time Miss F and Mr J raised concerns about RFM. Green-top guideline 57 says clinicians should confirm the presence of the foetal heart using a handheld doppler device when women report RFM before 28 weeks. This is a machine that gives live audio of blood flow and foetal heart rate. We have seen the midwife did this, so we consider the Trust acted in line with the relevant guidance.
Visit on 26 September 2018 (28 weeks)
44. Miss F and Mr J say she saw a midwife at the Trust as she had pink watery discharge. They say staff did a test for early labour but dismissed the discharge as unimportant. They say staff sent them home without any explanation about what the discharge was which left them scared and anxious.
45. Miss F’s watery discharge could have indicated preterm labour. We have seen the Trust excluded this in line with NICE CG190. A midwife did observations on Miss F and baby and did an examination. The findings did not suggest preterm labour.
46. The midwife found Miss F’s cervix closed on examination. This suggests she was not in preterm labour as the cervix stays closed during pregnancy. It gradually softens and decreases in length as the body prepares to give birth. They also did cardiotocography (CTG) that also suggested she was not in preterm labour. CTG is a technique used to monitor foetal heartbeat and uterine contractions.
47. An obstetrician then reviewed Miss F and noted a PartoSure test was negative. This is a test used to help decide if a woman is in preterm labour by measuring the level of a certain protein in vaginal secretions. The Trust went beyond NICE CG190 by doing this test which also suggested she was not in preterm labour.
48. Watery discharge could also have indicated preterm prelabour rupture of membranes (PPROM). PPROM is where the sac surrounding the baby breaks before 37 weeks of pregnancy. This puts the woman at increased risk of infection and at a higher chance of having her baby early.
49. At the time, NICE NG25 said clinicians should do an examination to check for pooling liquor when a woman reports possible PPROM. This is where a collection of amniotic fluid (the fluid surrounding the baby) can be seen in the back of the vagina on examination. We think the Trust excluded PPROM in line with NICE NG25.
50. The midwife did an examination and saw no pooling liquor, which suggested Miss F’s waters had not broken. It was appropriate to reassure her that all seemed well and to send her home. We appreciate why Miss F and Mr J still felt scared and anxious.
51. NICE NG25 also says clinicians should consider testing vaginal secretions for traces of amniotic fluid to help rule out PPROM more definitely. The Trust did not do a test, but we cannot criticise this as the guidance at the time only said to consider it. NICE updated its guidance in August 2019, so it now says to do a test. We understand the Trust started using these tests after Miss F’s and Mr J’s complaint.
52. Pink watery discharge could also have indicated a possible bleed. We have seen the midwife did an examination and noted no signs of bleeding. The obstetrician also noted no bleeding. We think the Trust investigated this in line with green-top guideline 63.
Telephone call and visit on 15 October 2018 (30+5 weeks)
53. Miss F and Mr J say she phoned the Trust with concerns about contractions, back pain, strong period-like pain and a pink mucous show (when the mucous from the cervix comes away). The midwife advised her to come in. They say they attended and the midwife told them everything was okay and Miss F had a urinary tract infection (UTI). They say they felt anxious as nobody seemed interested and staff were very quick to send them home which made them feel like an inconvenience.
54. Tightenings, a show and pain could have indicated preterm labour. The Trust excluded this in line with NICE CG190. The records show the midwife did observations of both mother and baby, including normal CTG. The records do not mention any tightenings or contractions. They also noted the cervix was long and closed on examination.
55. A registrar noted bleeding that was ‘not currently significant’ and advised Miss F to return if it worsened. In line with green-top guideline 63, the Trust should have taken further action to investigate this bleeding and kept Miss F in hospital. This is a failing. We consider this later in our report.
Antenatal appointment on 12 November 2018 (34+5 weeks)
56. Miss F and Mr J say a community midwife visited their home for an antenatal appointment. They say Miss F showed the midwife photographs of sanitary pads with pink watery discharge as well as the pad she was wearing. They say the midwife told Miss F it looked like her waters were leaking and referred her to the Trust.
57. Miss F and Mr J say they attended the Trust where a midwife took a swab to rule out infection (this later came back clear) and told them everything was fine. They say they were still concerned as the pink watery discharge was happening daily and staff gave them no explanation.
58. Watery discharge could have indicated PPROM. We have seen the midwife did an examination and saw no pooling liquor which indicated Miss F was not experiencing PPROM. We consider the Trust excluded this in line with NICE NG25.
59. Abnormal vaginal discharge could have indicated possible infection. We have seen the midwife did a vaginal swab to rule out infection. This was in line with the NICE antenatal care CKS.
60. The records confirm the community midwife saw photos of pink watery discharge. This could have indicated bleeding. The Trust did not take steps to exclude a bleed in line with green-top guideline 63. The midwife should have referred Miss F to obstetrics so a doctor could investigate this. This is a failing. We consider this later in our report.
Telephone call on 23 November 2018 (36+2 weeks)
61. Miss F and Mr J say she phoned the Trust with bad period-like pain, and pink watery discharge with blood loss. They say a midwife told her to call again if it got any worse. They say they felt pushed to one side and no better off after phoning for help.
62. The midwife’s notes say Miss F phoned with period-like pain, back pain, Braxton Hicks (contractions in preparation for giving birth) and she had passed a small amount of fluid and blood. The notes say they gave her some advice but not what this advice was.
63. Contractions, pain and watery discharge with blood loss could have indicated PPROM, preterm labour or bleeding. The midwife should have invited Miss F in for a review so they could assess and examine her in line with NICE NG25, NICE CG190 and green-top guideline 63.
64. This did not happen and this is a failing. We have considered what impact this had on Miss F and Baby R. We know Miss F did not go into preterm labour, but we consider this failing later in our report.
65. We note the Trust said in its RCA report that fluid loss and pains at this stage of pregnancy is not normal. It also said the midwife should have invited Miss F in for a review. This supports our findings.
Antenatal appointment and hospital admission on 26 November 2018 (36+5 weeks)
66. Miss F and Mr J say she again showed the community midwife photographs she had been taking of the pink watery discharge, as it was still worrying them. They say the community midwife advised them to go back to the Trust because she was sure her waters were leaking.
67. Miss F and Mr J say they went to the Trust and showed a midwife the photographs. They say Miss F was having regular contractions, so midwives started her on antibiotics and moved her to a ward. They say staff did not listen to their concerns that Miss F’s waters were leaking. They also say staff told Mr J he was going to become a dad.
68. At 36+5 weeks, Miss F was technically still preterm by two days. She presented with symptoms of possible preterm labour (tightenings or contractions, back pain, and watery discharge), PPROM (watery discharge) and bleeding (blood-stained discharge).
69. The Trust considered preterm labour in line with NICE CG190. The midwives thought Miss F may have been in threatened preterm labour as she was contracting four to five times every ten minutes. They took appropriate observations of her and Baby R by doing an examination and CTG. They also admitted her for further observation.
70. Our obstetrics adviser felt midwives should have referred Miss F to obstetrics for a review as she was still preterm. We agree this would have been in line with section 8.1 of the NMC’s Code. This says midwives must refer matters to colleagues when appropriate. We consider this a failing, but it did not have any impact as we know Miss F did not go into preterm labour.
71. The Trust excluded PPROM in line with NICE NG25. The midwives offered an examination to look for pooling liquor and saw none. The Trust did not consider bleeding in line with green-top guideline 63.
72. Miss F presented with blood-stained discharge. Midwives should have referred her to obstetrics so doctors could investigate the possibility of a bleed. This is a failing. We will consider this later in our report.
73. Miss F and Mr J complain the Trust gave Miss F antibiotics without a doctor seeing her first.
74. We have seen obstetrics advised midwives to give Miss F antibiotics during labour when they responded to the referral in May 2018. This advice is in line with green-top guideline 36 which says clinicians should offer women who are GBS positive preventative antibiotics during labour.
75. Midwives asked obstetrics to prescribe antibiotics during this admission. This was also in line with green-top guideline 36. Midwives reasonably believed Miss F may have been in preterm labour, obstetrics had advised them to give her antibiotics in labour, and a doctor then prescribed the medication.
76. Green-top guideline 36 says to give antibiotics at least four hours before the birth. Our midwifery adviser said preterm labour can happen quickly, so they thought it was reasonable for midwives to give Miss F antibiotics without a doctor seeing her. But our obstetrics adviser felt the doctor should have reviewed her first as part of established good care and treatment.
77. We agree it would have been in keeping with the GMC’s Good Medical Practice for the doctor to have seen Miss F. This is so they could establish whether she was in threatened preterm labour and needed antibiotics. Section 16a of Good Medical Practice says doctors must only prescribe drugs when they have enough knowledge of the patient’s health. We consider this a failing.
78. We have carefully considered what impact this failing had on Miss F and Baby R. We do not consider the decision to prescribe antibiotics without seeing Miss F to have caused her or Baby R any harm. She did appear to be in preterm labour and the decision to prescribe antibiotics was in line with guidance.
79. Miss F and Mr J also complain the Trust left her without any care between 7pm on 26 November and 11am on 27 November.
80. Looking at Miss F’s notes, the largest gap in care appears to be between 3.20am and 7.34am on 27 November. It is reasonable that midwives may have left her to try and get some rest given the time of night. We also note she had access to a call bell if she needed any help.
81. This part of Miss F’s care was in line with the NMC’s Code. Section 1.1 says midwives must make sure they deliver the fundamentals of care effectively. Section 1.4 says they must make sure they deliver any treatment or care for which they are responsible without undue delay. We hope this gives Miss F and Mr J some reassurance.
Telephone call and visit on 28 November 2018 (37 weeks)
82. Miss F and Mr J say she phoned the Trust as she could not feel Baby R move. She was also experiencing bad period-like pain and had pink watery discharge with blood in it. They say the midwife advised her to keep an eye on any movement and attend if she was not happy.
83. Miss F and Mr J say they attended later that day and a midwife gave her a clicker that measured only three movements over the course of two hours. They say they questioned Baby R’s lack of movement and high heart rate, but the midwife dismissed their concerns.
84. Miss F and Mr J say they asked if the RFM could be linked to the antibiotics from the day before and again raised concerns about leaking waters. They say the midwife panicked and said they were just following a process. They also say the midwife said she would request a scan, but this did not happen.
85. Miss F and Mr J say the midwife sent them home feeling very angry, upset, and extremely concerned about RFM. They say staff kept dismissing their worries and anxieties and telling them they should trust the professional judgment of clinicians as they know best.
86. The clinical records show Miss F phoned the Trust at 2.22pm with concerns about RFM. They say the midwife advised her to come in at 3pm and she arrived at that time. We consider the midwife appropriately advised her to attend so they could check Baby R was okay.
87. This was the second time Miss F had reported RFM, but the first time after 28 weeks in what was now a term pregnancy (37 weeks). Green-top guideline 57 says clinicians should do an ultrasound when a woman presents with RFM after 28 weeks and continues to be concerned after doing a CTG and the results being normal.
88. The records show the midwife referred Miss F for a scan after a normal CTG to make sure Baby R was doing well. This was in line with green-top guideline 57. But a consultant then cancelled the referral the next day as a doctor had seen Miss F on 27 November 2018.
89. Our obstetrics adviser felt the scan should have gone ahead as it would have provided an accessible and safe way of making sure Baby R was healthy. We agree a scan would have been in line with green-top guideline 57 and not doing one is evidence of a failing. We note the Trust acknowledged it should have done a scan and clinical review within its RCA.
90. Pain and pink watery discharge could have indicated bleeding, preterm labour, or premature rupture of membranes (PROM). This is where the membranes rupture after 37 weeks of pregnancy. We have seen no evidence that Miss F raised these concerns at the time, but we think she probably did. This is because she had raised them before and continued to raise them after this.
91. The records show the midwife did not take observations, do an examination or refer Miss F to obstetrics. The Trust did not take action to investigate her reported concerns about pain, fluid loss or possible bleeding in line with relevant guidance. This is a failing.
92. We know Miss F did not go into preterm labour, but we consider the impact of this failing later in our report.
Visit on 3 December 2018 (37+5 weeks)
93. Miss F and Mr J say they attended the Trust because Baby R’s movements were extremely limp and dull and Miss F was still experiencing pink watery discharge and contractions. They say the midwife said there was no evidence her waters were leaking and questioned whether she had wet herself, which she found embarrassing.
94. Miss F and Mr J say the midwife told them she was in early labour. They asked what they could do to bring labour on, and a doctor suggested a stretch and sweep every 48 hours (this is a procedure to try to start labour naturally). They say this visit made their anxiety worse and staff treated Miss F like she did not know what she was talking about. This made them feel like they were wasting NHS time.
95. This was the third time Miss F reported RFM and the second time after 28 weeks. Green-top guideline 57 says to do an ultrasound when a woman repeatedly presents with RFM after 28 weeks. It also says obstetrics should review her to exclude any possible causes. The midwife did a CTG and completed a referral for a scan and obstetrics review in line with guidance.
96. Miss F’s pink watery discharge and contractions could have indicated preterm labour, PROM or bleeding. The records show she also reported experiencing a show for one week. The midwife did an examination and found the cervix closed with no evidence of PROM or bleeding. An obstetrician then reviewed Miss F and noted the same.
97. Miss F’s care was in line with relevant guidance. The Trust excluded preterm labour, PROM and bleeding by taking both mother and baby’s observations and doing an examination in line with NICE CG190, NICE NG25 and green-top guideline 63. The midwife also referred Miss F for a scan and review in line with green-top guideline 57.
98. The ultrasound scan took place on 7 December 2018 which is outside the suggested 24-hour timeframe recommended in green-top guideline 57. The Trust has already accepted this delay. It did not have any impact as the scan was normal. But an obstetrics review did not take place on 7 December. We consider this further later in our report.
Telephone call and visit on 5 December 2018 (38 weeks)
99. Miss F and Mr J say she phoned the Trust as she was contracting and was still concerned about Baby R’s movements. The Trust advised her to attend, and a midwife said she was still in early labour. They say she was distressed and upset and pleaded with staff to induce her as she had been in early labour for some time.
100. Miss F and Mr J say they told the midwife it would be better to start labour now so staff could monitor Baby R and deliver her safely. They shared their concerns that Baby R had become very limp and weak since Miss F had antibiotics. She was also still experiencing pink watery discharge which they believed to be her waters leaking.
101. Miss F and Mr J say the midwife told them the discharge was perfectly normal and there was no clinical need for induction as labour would happen naturally. They say they tried to argue it would be better to be in hospital where staff could give Miss F antibiotics, but the midwife dismissed this and sent them home again. They felt stressed, ignored, and like nobody was taking them seriously.
102. Contractions and watery vaginal loss could have indicated Miss F was going into labour or experiencing PPROM. We think the midwife considered this and assessed her appropriately. The examinations suggested she was not going into labour and her waters had not broken. Miss F’s membranes were intact, there was no change to her cervix and the midwife saw no pooling liquor.
103. This part of Miss F’s care and treatment was in line with green-top guideline 57 and NICE NG25, until she reported pink watery fluid loss. This could have been an unidentified bleed. The midwife should have escalated this to obstetrics for a review in line with green-top guideline 63. This is a failing.
104. The records show Miss F requested an induction and the midwife told her there was no clinical need. Both our advisers said the midwife should have referred Miss F’s request to obstetrics. This would have been in line with section 8.1 of the NMC’s Code which says midwives must refer to colleagues when appropriate. This is a failing.
105. There is no record of Miss F and Mr J raising concerns about RFM during this visit. But we again think they likely did. This would have been the fourth time Miss F had raised concerns about RFM and the third time after 28 weeks.
106. The Trust should have done a CTG to check Baby R was well and referred Miss F for an ultrasound and obstetrics review in line with green-top guideline 57. It is a failing this did not happen. We do not think there was a direct impact as a midwife had already referred Miss F on 3 December 2018.
107. Overall, Miss F’s care on 5 December 2018 was not in line with relevant guidance. The Trust did not take appropriate action to investigate possible bleeding or RFM. It also did not refer Miss F to obstetrics after she asked for an induction. These were failings and we look at them further later in our report.
Stretch and sweep appointment on 6 December 2018 (38+1 weeks)
108. Miss F and Mr J say she told the midwife at her stretch and sweep that Baby R’s movements were still worrying her as they were minimal. They say the midwife told her not to worry as she was having a scan the next day.
109. We cannot see any record that Miss F raised concerns about RFM during this appointment, but, again, we think she likely did. This would have been the fifth time she had raised concerns and the fourth time since 28 weeks.
110. In line with green-top guideline 57, the midwife should have done a CTG to check Baby R’s movements or referred Miss F to a colleague to do this. They should also have referred her for an ultrasound and obstetrics review. It is a failing this did not happen.
111. We have considered the impact of this. We know a midwife had already referred Miss F for a scan and obstetrics appointment on 3 December 2018 so we find there was no direct impact. We look at this further later in our report.
Ultrasound and appointment on 7 December 2018 (38+2 weeks)
112. Miss F and Mr J say the person who did the scan said they were having a fit and healthy baby girl. They then went for their appointment with a consultant but saw a midwife, as no doctor was available. They say they pleaded for an induction as Miss F could not cope with the pain, stress and worry about Baby R not moving properly.
113. Miss F and Mr J say at this point she had not been sleeping properly and was extremely fatigued. They say the midwife said she could not induce her, and she was having stretch and sweeps to bring labour on. The midwife told them she would make an appointment with a consultant and advised them to go home and rest.
114. We cannot see any record of the discussion with the midwife. But we think Miss F likely asked to be induced as she had already asked on 5 December 2018. Again, both our advisers said the midwife should have referred any request for induction to obstetrics. This is a failing.
115. We also think Miss F likely raised concerns about RFM. This would have been the sixth time she had raised concerns and the fifth time since 28 weeks. The midwife should have done a CTG to check Baby R was well and referred Miss F for a scan and obstetrics review in line with green-top guideline 57. It is a failing this did not happen.
116. We have considered the impact of this. We recognise Miss F had a scan earlier the same day and the midwife did refer her to obstetrics. We note the Trust’s RCA says they only made the referral due to Miss F’s long latent phase (the beginning part of the first phase of labour) rather than RFM. We will consider this further later in our report.
Stretch and sweep appointment on 8 December 2018 (38+3 weeks)
117. Miss F and Mr J say the midwife told her she could break her waters, but she was not allowed. They say Miss F was stressed as Baby R was limp and lifeless, but the midwife took no action.
118. We cannot see any record that Miss F raised any concerns about RFM, but we think she did. This would have been the seventh time she had raised concerns and the sixth time after 28 weeks.
119. In line with green-top guideline 57, the midwife should have done a CTG to check Baby R’s movements or referred Miss F to a colleague to do this. They also should have referred her for an ultrasound and obstetrics review. It is a failing this did not happen.
120. We have considered the impact of this. We have seen the midwife monitored Baby R’s heart rate before and after the stretch and sweep and noted normal movements. We again also recognise Miss F had a scan the day before and a midwife had already referred her to obstetrics. We consider this further later in our report.
Overall antenatal care
121. Miss F presented with concerns about bleeding, fluid loss and RFM many times particularly during her third trimester. We have found the Trust did not always investigate these in line with relevant guidance. More importantly, staff did not listen to her concerns and there was a lack of continuity in her care which meant nobody took a holistic view of what was happening.
122. It would have been in line with the NMC’s Code for midwives to have referred Miss F to a senior obstetrician, considering how many times she presented with concerns. Section 8.1 of the Code says midwives should refer matters to colleagues when appropriate. Section 8.5 says they should work with colleagues to preserve the safety of those receiving care. Section 8.6 also says they should share information to identify and reduce risk.
123. Midwives should have referred Miss F to a senior consultant as early as 26 September 2018 when she reported concerns about fluid loss for a third time. We note clinicians at the Trust’s professional review meeting felt a consultant should have seen Miss F due to her many attendances. The Trust also now refers women to a consultant after three unscheduled antenatal visits.
124. We have decided Miss F raised concerns about RFM many times although we recognise this is not always shown in her notes. We have found her account compelling, especially considering how many times she attended with concerns. Poor record-keeping may have led to a lack of shared understanding about her experience of RFM which affected her care.
125. Green-top guideline 57 says ‘women who present on two or more occasions with RFM are at increased risk of a poor perinatal outcome’. It also says, ‘the decision whether or not to induce labour at term in a woman who represents recurrently with RFM when the growth, liquor volume and CTG appear normal must be made after careful consultant-led counselling of the pros and cons of induction on an individualised basis.’
126. This guidance indicates a consultant should have reviewed Miss F to consider whether to induce her at term (37 weeks) due to her concerns about RFM. Midwives should have referred her to a consultant when she reported RFM for a second time on 28 November 2018. They also should have referred her requests for induction on 5 and 7 December 2018.
127. We recognise Miss F’s ultrasounds, including the one on 7 December, all appeared normal. But green-top guideline 57 is clear that it is for a consultant to decide whether to induce a woman presenting with recurrent RFM even when everything else seems normal, by weighing up the pros and cons.
128. A senior obstetrician should have reviewed Miss F in a non-emergency setting considering how many times she presented with concerns particularly about RFM. Instead, she was seen by lots of different clinicians. She needed an experienced obstetrician to carefully listen to her concerns and consider them as a whole.
129. A senior obstetrician could have considered whether Miss F’s waters were leaking, whether she had a bleed and if she needed to be induced. This input would have also helped address Miss F and Mr J’s obvious distress and anxiety. We recognise how distressing the pregnancy must have been for them particularly as they had experienced two miscarriages before.
130. The Trust should have graded Miss F’s pregnancy as high risk and put her under the care of a consultant. We realise a consultant may have reduced her risk to low and decided midwives could safely care for her in the community. But she may have had an antenatal schedule organised under a consultant with visits to a consultant clinic.
131. The Trust should have revisited Miss F’s risk during her pregnancy and increased it considering how many times she attended with the same concerns. It is much less likely the failings would have happened if midwives had graded her pregnancy high risk and she had been under the care of a consultant. We have considered the impact of these failings below.
Impact
132. Miss F and Mr J believe the Trust could have safely delivered Baby R had it provided better care and treatment and induced labour sooner. They told us how the events caused them and their whole family a great deal of emotional and psychological distress.
133. We cannot begin to imagine how devastating losing Baby R has been for them and their loved ones. We have carefully considered the impact of the failings and if the Trust could have saved Baby R.
134. Our obstetrics adviser told us how the cause of death sadly cannot be decided in many stillbirths. They agreed with the Trust that it is not possible to be sure why Baby R died. They said the post-mortem lists infection as a contributory factor rather than the major factor. They said infection may be the most likely cause in the absence of anything else.
135. Our obstetrics adviser thought Miss F mostly likely had a slow hind water leak. This is where there is a puncture high up from the cervix and the amount of liquor released is usually minimal which means it can sometimes be confused with vaginal discharge. It would have allowed infection into the amniotic sac (the sac that surrounds the growing foetus). They think this led to infection being the most likely cause of Baby R’s death.
136. We have thought carefully about what a consultant would have done if they had reviewed Miss F. We think they would have considered whether to induce labour. This would have been in line with green-top guideline 57 and clinically appropriate considering how many times she attended with the same concerns.
137. We started by thinking about the reasons not to induce. Our obstetrics adviser explained how induction can involve spending several days in hospital in a lot of discomfort. They said one of the main concerns obstetricians have is that induction will not work, and they then have to consider whether to do a caesarean section which has its own risks.
138. Our obstetrics adviser said induction also increases the chance of a difficult labour and distress to the baby. They said it increases the chance of postpartum complications and the risk of most of the complications associated with delivery. They said there is around a 50% chance a woman will need a caesarean if she is induced during her first pregnancy.
139. We then thought about the reasons to induce. Miss F was at term (37 weeks) on 28 November 2018. This was her third pregnancy, her pregnancies before led to uncomplicated vaginal deliveries, and she had been successfully induced before. Our obstetrics adviser said these all mean the risks associated with induction were much lower.
140. Miss F had persistently raised concerns about possible bleeding, RFM and vaginal loss, and the Trust had not done a test to definitively exclude PPROM/PROM. This means she could have had an undiagnosed issue, such as a hind water leak, which put her and Baby R at risk. We also know she was experiencing a great deal of anxiety and distress.
141. Our obstetrics adviser agreed a factor in favour of induction would have been the distress and anxiety Miss F must have been experiencing at the time. They explained that obstetricians often induce women at term who attend frequently with concerns like Miss F had, even if the relevant guidance does not recommend it.
142. We also think Miss F would have wanted to be induced based on how many times she raised concerns, how worried she was and because she started to request it near the end of her pregnancy. Our obstetrics adviser told us obstetricians will often agree to a request for induction at term when there are significant or ongoing concerns, unless there is an obvious reason not to proceed.
143. Overall, our obstetrics adviser thought a consultant would have very likely agreed to induce Miss F at either 39 or 40 weeks. We recognise this would have been too late to save Baby R. But we know Miss F attended the Trust six separate times in early December with the same concerns. Our view is it is likely a consultant would have brought any planned induction forward when she continued to raise concerns.
144. We have decided it is most likely the Trust would have safely delivered Baby R if it had induced Miss F on or before 9 December 2018. We know how upsetting this finding will be for Miss F and Mr J. We have made recommendations to address this injustice at the end of our report.
Staff attitude
145. Miss F and Mr J complain about the attitude of staff they saw throughout her pregnancy and after Baby R’s death. They say members of staff, particularly midwives, were unprofessional, uncaring and insensitive. We are deeply concerned to hear of their experience.
146. Miss F and Mr J complain they generally felt they were not listened to or taken seriously. They say staff made them feel like they were wasting their time. They also say staff spoke to them in a demeaning way which left Miss F feeling like she did not have a voice. We know from speaking with them how much this affected them.
147. Miss F and Mr J gave us several examples to support their concerns. We have detailed some of these below:
• a midwife made an inappropriate comment while taking a vaginal swab on 26 September and her and another midwife laughed at this • a midwife questioned whether Miss F had wet herself when she raised concerns about fluid loss on 3 December • midwives told Miss F everything was okay when they could not find Baby R’s heartbeat in early December • a midwife made inappropriate comments after Baby R’s death about how staff would take any concerns more seriously if they were to have another baby at the Trust because of what had happened to Baby R • midwives separated Miss F and Mr J during her postnatal hospital admission in December • during the postnatal admission, midwives put Mr J in the room where he and Miss F had found out Baby R had died and where he could hear another woman with the same name as Miss F giving birth to a healthy baby • during her postnatal admission midwives told Miss F her pain was all in her head and she just needed tough love
148. Section 1.1 of the NMC’s Code says midwives must treat people with kindness, respect and compassion. Section 2.6 says midwives must recognise when people are anxious or in distress and respond compassionately and politely.
149. The attitude and behaviour Miss F and Mr J have described to us fell well below these professional standards. We find parts of their account very troubling. This amounts to a failing and we will consider the impact of this below.
Impact
150. Miss F and Mr J say they felt helpless, vulnerable and unsafe throughout the pregnancy.
151. Poor staff attitude made the pregnancy more upsetting and stressful than it should have been. It also affected their relationship with staff and their confidence in the Trust. Staff did not listen to Miss F and this affected the care they gave her.
152. We recognise the Trust has already accepted Miss F and Mr J should have left feeling cared for and they did not. It also said it clearly did not give them emotional support. The Trust said it was truly sorry for their distress and that it had fed this back to staff and tried to identify those concerned.
153. Our ‘Principles for Remedy’ say organisations should return complainants who have suffered an injustice to the position they were in before the poor service happened. If that is not possible, the organisation should compensate them appropriately.
154. We know the Trust cannot change Miss F and Mr J’s experience, but it should compensate them for what happened. We also consider it has not taken appropriate steps to stop the same things from happening again. Because of this, we have made recommendations at the end of this report.
Bereavement care
155. Miss F and Mr J complain the Trust gave them poor bereavement care after Baby R’s death. They say they only saw the bereavement midwife twice, she did not give any support and she did not help with parking fines they got while Miss F was in hospital. They also say they received letters and a phone call from other organisations as the Trust did not tell them about Baby R’s death.
156. In October 2018, the NBCP launched nine bereavement care standards it says every NHS trust should follow. We recognise these are not currently mandatory, but they provide a good framework for NHS trusts to follow. The standards suggest:
1. a parent-led bereavement care plan is in place for all families, giving continuity between settings and into any later pregnancies
2. bereavement care training is offered to staff who come into contact with bereaved parents, and staff are supported to access this training
3. all bereaved parents are informed about and, if requested, referred for emotional support and for specialist mental health support when needed
4. there is a bereavement lead in every healthcare setting where a pregnancy or baby loss may happen
5. bereavement rooms are available and accessible in all hospitals
6. the preferences of all bereaved families are asked for and all bereaved parents are offered informed choices about decisions relating to their care and the care of their babies
7. all bereaved parents are offered opportunities to make memories
8. a system is in place to clearly signal to all health care professionals and staff that a parent has experienced a bereavement to enable continuity of care
9. healthcare staff are provided with, and can access, support and resources to deliver high-quality bereavement care.
157. We have found the Trust met standards three to seven. Miss F gave birth in a bereavement suite, and the Trust offered opportunities to make memories. This included family visits, keeping a lock of Baby R’s hair and having a photographer. Miss F and Mr J also had access to a bereavement midwife who directed them to sources of support, and the Trust referred her to the community mental health team for specialist help.
158. We have found the Trust went some way to meeting standard one. We have seen no evidence of a parent-led bereavement care plan. This would have meant the Trust had a clear record of an agreed level of support from the beginning that staff could have revisited and recorded progress against. The records suggest there was some plan in place but this is not clearly set out and progress is not recorded.
159. The records say the bereavement midwife visited Miss F and Mr J in hospital on 17 and 18 December 2018. She told them the Trust would be investigating what happened to Baby R, apologised for their experience, provided information about support, and said she would visit them again once they were home.
160. The bereavement midwife phoned Miss F on 24 December 2018. The notes refer to her mental health being poor and that she had been having suicidal thoughts. They say Miss F had been in touch with the community mental health team who were ‘less concerned about her’.
161. Another midwife phoned Miss F on 28 December 2018 to see how she was doing and to ask if she would like any more visits. The notes say Miss F had seen the bereavement midwife earlier that day (we have seen no record of this). The notes also say Miss F declined any more contact.
162. The bereavement midwife visited Miss F and Mr J on 11 January 2019. The notes say they were talking more effectively and had accepted Baby R’s death but were still sad and searching for explanations. She told them someone was going to be contacting them about the Trust’s investigation. They discussed Baby R’s funeral, Mr J returning to work, coping strategies and support for Miss F.
163. The bereavement midwife phoned Miss F and Mr J on 31 January 2019. The notes say they were coping well and were able to talk to each other about Baby R. They had an appointment with the Trust to discuss its investigation and Mr J had returned to work and was feeling okay. They were upset they were still getting parking charges from their time in hospital after Baby R’s death and the midwife said she would contact security to sort this out.
164. The bereavement midwife phoned Miss F on 6 March 2019. The notes say she was struggling with nightmares and feeling disconnected. The midwife recommended coping strategies, provided information about support groups and helplines, and advised her to talk to her GP.
165. Overall, while the notes of the bereavement midwife’s phone calls and visits are incomplete and brief, they do show they provided Miss F and Mr J with a level of support mostly in line with the NBCP Standards. We recognise the records may not reflect Miss F and Mr J’s experience. We also recognise the care could have been more structured.
166. The bereavement midwife visited Miss F and Mr J twice in hospital, twice at home and contacted them four other times. She spoke with them about how they were feeling, directed them to sources of support and attended the meeting about the post-mortem as well as Baby R’s funeral. She was also aware Miss F was in contact with the community mental health team who were best placed to help with any mental health issues.
167. We have found the Trust did not meet standard eight. The Trust has already said it did not have a good system in place for telling other organisations about what had happened to Baby R. This led to Miss F and Mr J getting upsetting letters about baby classes as well as a phone call from a health visitor.
168. The Trust has also already accepted Miss F and Mr J got distressing letters from a private parking company about charges while Miss F was in hospital. The Trust said it was extremely sorry about what happened and it now has a process where ward staff can exempt people from parking charges.
169. The Trust said the bereavement midwife did contact its car parking team about the fines but recognised she did not communicate this to Miss F and Mr J. The issues relating to standard eight amount to a failing. We consider the impact of this below.
170. Miss F and Mr J also say they got harassing phone calls from the bereavement midwife. They say she tried to find out who Mr J’s aunt was after she went with them to the meeting to discuss the post-mortem results on 28 February 2019.
171. The Trust told us Mr J’s aunt asked several questions of a legal nature, so the bereavement midwife asked about her during their next phone call with Miss F. The Trust said the midwife could not remember the details of the call but did not feel it was harassing and only wanted to clarify her relationship to Miss F and Mr J.
172. We understand Mr J’s aunt told staff at the meeting on 28 February 2019 she was his aunt and asked some questions about the Trust’s investigation into Baby R’s death. From the Trust’s comments, it seems staff may have been concerned she was a legal representative.
173. We consider it was inconsiderate and unnecessary of the bereavement midwife to ask about Mr J’s aunt during a phone call that should have been focused on bereavement care. We consider this was not in line with section 1.1 of the NMC’s Code. We can appreciate why Miss F and Mr J found this concerning and led them to feel the Trust was more focused on protecting itself.
174. Overall, there were several parts of the Trust’s bereavement care which fell short of the NBCP standards and NMC Code. It could have planned the care better and kept better records of its progress. It should have advised other organisations of Baby R’s death and resolved the issues with its parking company sooner. It also should not have questioned who Mr J’s aunt was. These issues amount to a failing.
Impact
175. Miss F and Mr J say the Trust’s bereavement care caused them added distress and upset at an already difficult time.
176. We are very sorry to hear of their experience. We know receiving letters about baby classes and parking fines as well as a phone call from a health visitor must have been incredibly distressing for them. This happened at one of the most, if not the most, difficult time in their lives.
177. We recognise the Trust has already acknowledged this, apologised, and made changes to its service to stop this from happening again to someone else. Because the Trust cannot change what happened and has not compensated Miss F and Mr J, we have recommended it takes further action at the end of our report.
Cannula care
178. Miss F and Mr J complain staff did not fit her cannula properly and delayed doing anything about it when they raised concerns. This happened towards the end of her admission in December 2018. They say this caused her pain and prevented her from getting pain relief.
179. We can only see two issues relating to cannula care in Miss F’s notes. A midwife noted the two cannulas in her left hand were sore, one had stopped working and the other was painful, so they removed them. Two days later, Miss F said she was concerned about a red swelling around the remaining cannula in the pit of her elbow. A midwife checked it but found no issues.
180. We recognise Miss F and Mr J’s account is different from the records. The Trust has already acknowledged its record-keeping around cannula care was poor. We agree and it has made looking at this part of the complaint difficult. We have seen the Trust has also already apologised for the fact that staff did not listen to Miss F’s concerns or inspect her cannula as they should have. We cannot add anything further to this. We know this will be disappointing for them.
181. We have seen the Trust switched Miss F to oral pain relief. This means, even if there were issues with her cannula after this time, it should not have affected her pain relief. We hope this gives Miss F and Mr J at least some reassurance.
Trust’s root cause analysis (RCA)
Time to complete the RCA
182. Miss F and Mr J complain the Trust’s RCA investigation took too long. We know from speaking with them how difficult they found this process as they understandably wanted answers about what had happened to Baby R.
183. The Trust’s incident reporting policy says the lead investigator should complete the investigation and produce a draft report within 20 days of an incident (this would be the end of December 2018 in this case).
184. It is difficult to see when the lead investigator completed the draft report. But they only took staff statements on 22 January 2019 and met with Miss F and Mr J on 13 February. So, it is clear the draft report was completed well outside 20 days.
185. The Trust’s duty of candour policy says it should complete a final report within 60 days of an incident being reported (this would be in February 2019 in this case). The operational governance committee approved the RCA report on 11 March 2019 subject to amendments.
186. It seems the lead investigator completed these amendments on or around 15 March 2019. We can see a ‘final’ version of the RCA report was shared with staff on this day. This means the Trust took over a month longer than its local policy says to produce its final report.
187. The Trust then shared this report with Miss F and Mr J in person on 5 April 2019. We understand Miss F and Mr J requested some minor changes to the report and the Trust shared an amended version on 26 April. It then held a serious incident closure meeting on 8 May and provided a further version of the report on 13 May.
188. Miss F and Mr J told the Trust they were still unhappy with some sections of the report on 14 May. The Trust shared a further version on 12 June. They emailed the Trust with some further comments on 19 June and the Trust provided a final version on 26 June.
189. We can appreciate why Miss F and Mr J are upset about what happened between April and June 2019. We know it can sometimes take time to reach a stage where all parties are satisfied with a report like this. But the Trust could and should have resolved the comments much quicker, particularly as the amendments were minor.
Communication around RCA
190. Miss F and Mr J complain they did not feel informed or supported throughout the RCA process. We recognise this would have been very difficult for them and they must have been desperate for answers.
191. The Trust’s incident reporting policy says the lead clinician will inform the family of the intention to investigate the incident, the reasons for the investigation and agree a contact person and method of feedback. It says it is best practice for the lead investigator to meet with the family as part of the investigation and they must document any discussions.
192. The bereavement midwife visited Miss F and Mr J in hospital on 17 and 18 December 2018. During one of these visits, she advised them that the Trust would be investigating what happened to Baby R. During a visit to their home on 11 January 2019, the bereavement midwife said someone from the Trust would be contacting them about the investigation.
193. We understand the lead investigator then met with Miss F and Mr J at their home on 13 February 2019. This would have been an important meeting where the lead would get their account of what happened. There is no record of the visit, the phone call or emails to arrange it. This is not in line with the Trust’s incident reporting policy.
194. We understand the lead investigator met with them again at their home on 5 April 2019 to share the outcome of the investigation. Again, there is no record of this meeting or the phone call or emails to arrange it. There is a Word version of the RCA report which apparently includes their comments on the report itself. This is not in line with the Trust’s incident reporting policy either.
195. Overall, the Trust did not keep Miss F and Mr J updated, informed or supported during the investigation. The level of communication was not in line with the Trust’s local policy or our ‘Principles of Good Administration’. These say organisations should be helpful, communicate effectively and treat people with sensitivity. We consider this further later in the report.
196. We recognise the Trust has already apologised for Miss F and Mr J not feeling informed and supported. The Trust also said the patient safety team now writes to families to outline timescales, identify a point of contact and agree how often to keep in touch. These actions were already in the Trust’s incident reporting policy and did not happen.
RCA report
197. Miss F and Mr J complain the RCA report said there was no wrongdoing by any member of staff. They also say it does not consider what the post-mortem said was a contributory factor in Baby R’s death.
198. The Trust’s incident reporting policy says all serious incidents require a comprehensive RCA investigation. It says the purpose of this is to determine what happened, the underlying causes and what the Trust needs to do to stop it from happening again. It says the purpose of the investigation is not to blame people.
199. We understand why Miss F and Mr J want to know who, if anyone, made any individual mistakes in her care. We also recognise this is not the purpose of an RCA investigation. We hope our report has addressed the concerns they still have about what happened.
200. We do have some concerns about the RCA report itself. We think there are several areas where it identifies an issue or concern but does not go on to explore this further or come to a view on what happened. For example:
• the report says it was not normal for Miss F to experience tightenings on 5 September • the report says it was not normal for Miss F to have pink/brown vaginal loss on 12 September as this could have indicated bleeding • the report says there was discussion about whether Miss F needed a speculum examination and review by an obstetrician on 3 December • the report says there was discussion about whether staff would have made a different decision about induction, or referral to an obstetrician, had they considered the number of admissions, long latent phase and reports of RFM • the report refers to the results of Baby R’s post-mortem but does not discuss what they mean in terms of the care it provided to Miss F.
201. We also note the RCA makes little reference to whether the Trust’s actions and policies were in line with national guidance. For example, for a first episode of RFM after 28 weeks, it says local policy is to check the baby’s movements using CTG, reassure the woman and discharge with advice. This is not in line with green-top guideline 57.
202. We have other concerns about the way the Trust investigated what happened. We have seen the lead investigator took three staff statements (the midwife Miss F saw on 14 May 2018, the community midwife she saw a number of times and the midwife she saw on 12 September 2019). They did not interview any other staff involved in Miss F’s care and the statement from the community midwife does not cover clinical care at all. We consider this further below.
Overall
203. Overall, we find the Trust did not do the RCA in line with its own incident reporting policy. We think the different issues we have seen with the Trust’s RCA investigation amount to a failing. We consider the impact of this later in our report.
Trust’s complaint handling
Time to respond to complaints
204. Miss F and Mr J complain the Trust took too long to respond to their complaint. We know how distressing it can be to wait for a response particularly when you have suffered a devastating loss.
205. Our ‘Principles of Good Complaint Handling’ say organisations should deal with complaints quickly, in line with local timescales and avoiding unnecessary delay. The Trust’s complaints policy gives a target of 35 working days. It took 65 working days to provide its first response and 62 working days to provide the second.
206. Our ‘Principles for Good Complaint Handling’ also say organisations should keep the complainant regularly informed about progress and the reasons for any delays. The Trust did warn Miss F and Mr J it was going to miss its deadline, but this was often only just before a response was due, and it usually gave no reason why.
207. Overall, the Trust exceeded the timescales set out in its complaints policy. The deadlines it set itself were unrealistic in a serious and complex complaint such as this. Its aim to provide the second response within 20 working days was particularly unrealistic. It also did not keep Miss F and Mr J updated on what was happening. We consider this further later in the report.
Complaint responses
208. Miss F and Mr J complain the Trust was not open and honest with them about what went wrong. They also say the RCA report and complaint responses contradict each other.
209. Our ‘Principles of Good Complaint Handling’ say organisations should be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations and reasons for their decisions. When things have gone wrong, they should explain fully and say what they will do to put things right.
210. Looking at the RCA report and the Trust’s complaint responses, particularly its first response, there are discrepancies. The first response does not reflect the issues highlighted during the RCA, particularly around whether a consultant should have reviewed Miss F or looked at her overall concerns. We find the Trust was not always open and honest in its responses.
211. The Trust’s first complaint response was particularly poor especially considering the seriousness of the complaint. Despite being 30 working days late, it did not cover many of the issues raised and only partly addressed others. It also provided poorly worded apologies such as ‘I am sorry that you feel…’. We recognise the Trust’s second response was better. We consider this further below.
Service improvements
212. Miss F and Mr J complain the Trust has not put in place the service improvements it told them it would. They say they recently had a baby at the Trust and experienced some of the same issues again particularly in relation to poor staff attitude from midwives.
213. It is very concerning to hear Miss F and Mr J have experienced similar issues in another pregnancy. We understand why this has caused them to question whether the Trust has really learned from what happened. We hope the recommendations we have made at the end of this report makes sure the Trust improves its service.
214. Overall, we do not think the Trust’s complaint handling was in line with its complaints policy or our Principles. We consider the issues we have seen amount to a failing. We have considered the impact this had on Miss F and Mr J below.
Impact
215. Miss F and Mr J say the Trust’s RCA and complaint handling added to their distress and left them with ongoing questions and concerns about what happened. It is clear from our conversations with them that it did cause a great deal of upset at an already incredibly challenging time.
216. We recognise how hard it must have been to wait so long for the Trust’s RCA report and then each complaint response. The Trust caused more distress by repeatedly delaying its responses, with little notice and often no explanation why. We also know its report and responses did not address all their concerns.
217. The Trust has already acknowledged some of the issues we have seen but it has not recognised everything that went wrong. It has not taken appropriate steps to put right the injustice for Miss F and Mr J or to improve its service. We have made recommendations to address this. We sincerely hope our report has answered Miss F and Mr J’s concerns.