4. Mrs D complains the Trust failed to manage her care correctly following a miscarriage in February 2024. She says it did not use the correct equipment for an internal examination or provide follow up care.
5. Mrs D says the Trust’s lack of care and sensitivity made an already traumatic experience much worse. She says she cannot talk about the experience without crying which has impacted her mental health. She wants financial compensation.
6. Mrs D attended the emergency department (ED) in early February 2024 due to a potential miscarriage. The Trust the booked her in for an ultrasound scan two days later but as it couldn’t confirm findings it arranged a second scan which confirmed she had miscarried. She continued to bleed and had a further scan that confirmed the completion of the miscarriage by mid-March.
Equipment 9. Mrs D complains the Trust did not use the correct equipment during an internal examination to check if she had miscarried during her attendance in February 2024. She says during the examination, the gynaecologist could not find the correct equipment and asked if he could use her mobile phone as a torch. She has told us she felt she had no choice but to agree.
10. We can see in the records, Mrs D attended the ED with a suspected miscarriage in early February. Following triage, a gynaecologist made the decision to see her in the ED rather than her wait for a transfer to the surgical assessment unit. This was due to the length of time she had been waiting in the ED and the nature of her attendance. The internal examination took place in a side room.
11. The Trust provided a statement from the gynaecologist who says before the examination he sourced the equipment needed but could not find a torch as the emergency bag was missing. He says his options was to delay the examination further or to ask if we could use Mrs D’s phone for the torch which she agreed to.
12. GMC good medical practice say you must make good use of the resources available to you, and provide the best service possible, taking account of your responsibilities to patients.
13. In its final response, the Trust acknowledged that its communication with Mrs D was lacking here, and it should have involved her in the decision on how to proceed with the examination and whether she was happy to accept a delay while it found the correct equipment. It also recognised using a patient’s phone for a torch was not ideal.
14. The Trust also acknowledged it needed an alternative provision for women experiencing pregnancy loss so they can receive the correct care in a quieter and private area and said it is actively seeking a location for this. It also took action to ensure the correct equipment is always available for the on-call gynaecologist. It apologised to Mrs D for how the experience made her feel.
15. We are satisfied that the Trust’s acknowledgement and apology for Mrs D’s experience and the action it has taken to learn and improve, are in line with our principles which says organisations should learn from complaints to improve public services.
16. As the outcome Mrs D is seeking is a financial remedy. We have considered the impact that we can link from this specific failing we have seen. She told us the Trust’s lack of care and sensitivity made an already traumatic experience worse, and she cannot talk about the experience without crying which has impacted her mental health.
17. It is clear from what she told us, how distressing she found the Trust using her mobile phone as a torch during an internal examination. We cannot say it caused all the impact she has told us about as we have to consider that at the time she was experiencing her second miscarriage, and this would have also impacted her mental health.
18. We have considered our financial remedy scale, and we would not recommend a financial remedy for this level of upset. We do appreciate that if the Trust had followed guidelines, it would have eased her overall distress and upset. We are satisfied an acknowledgement, apology and service improvements are enough to address the impact caused by the failing outlined above. We will therefore take no further action on this part of the complaint.
Follow up care 19. Mrs D complains the Trust did not provide the correct care following her miscarriage in early February. She told us the nurses she saw during her attendances for ultrasound scans on two occasions later in the month, lacked empathy which added to her distress. She says during a welfare call in mid-February she told a nurse she was continuing to bleed, and they just advised her to wait to see if it eased. She says she continued to raise concerns with the service as she was still bleeding heavily. She says it was not until mid-March that the Trust eventually offered her a further scan where it told her the miscarriage had completed. Mrs D is unhappy at the length of time she had to wait for this.
20. NICE guidance on miscarriage says to use expectant management, which is a watch and wait process which monitors a patient’s condition without providing treatment for seven to fourteen days for women with a confirmed diagnosis of miscarriage. It goes on to say offer a repeat scan if after the period of expectant management, the bleeding and pain has not started (suggesting that the process of miscarriage has not begun) or is persisting (suggesting incomplete miscarriage).
21. We have seen in the records, following her ED attendance in early February with a potential miscarriage, the Trust booked Mrs D in for an ultrasound scan two days later. As it could not confirm findings it arranged a second scan which confirmed she had miscarried.
22. After her second scan, Mrs D opted for the expectant management process and agreed to take a pregnancy test three weeks later. The Trust then contacted her by phone in mid-February, but it was unable to make contact. It then spoke to her briefly in late February and early March where she advised, she was still experiencing light bleeding and was due to take a pregnancy test within a week. The Trust gave Mrs D advice to contact its service again if the pregnancy test was positive or she continued bleeding.
23. Mrs D spoke with the Trust to advise she was still bleeding after she had taken her test, and it arranged a further scan later in March where it confirmed the completion of the miscarriage.
24. Based on the records and Mrs D’s explanations about what happened it appears the Trust acted in line with NICE guidance in the management of Mrs D’s symptoms following her attendance at the ED with a suspected miscarriage. The guidance says to watch and wait.
25. We do not consider the Trust got anything wrong in its actions relating to her follow up care and we will therefore take no further action with this part of the complaint. We are sorry for any further distress this may cause.
26. We were sorry to hear of Mrs D’s experience, and from what she has told us it is understandable that she continues to struggle both emotionally and mentally. We hope our explanations above will give her reassurance, we have not found the Trust got anything wrong in its actions relating to her follow up care and we are satisfied it has done enough to address the impact caused by the failing outlined above. We will therefore take no further action on the complaint.
1. We have carefully considered Mrs D’s complaint about Mid Yorkshire Teaching NHS Trust (the Trust). We were sorry to hear about her experience and how this continues to impact her health and emotional wellbeing.
2. We have looked at the evidence provided to us by Mrs D and the Trust, and we have seen it did not act in line with relevant guidance when it continued with an intimate examination without the correct equipment. We are satisfied that the actions of the Trust when it acknowledged and apologised for Mrs D’s experience in relation to the missing equipment and the action it has taken to learn and improve, are enough to remedy this complaint and we will therefore take no further action on this part of the complaint.
3. We have also looked at all the evidence provided to us in relation to Mrs D’s follow up care and we have seen that the Trust followed relevant guidance. Therefore, we will not take further action on this part of the complaint. We are sorry for any additional upset this may cause, and we hope our explanations below explain how we have fully considered this.