Inconsistent explanations regarding sweep, staff failing to follow badger notes regarding J’s blood test, lack of documentation of blood test samples, lack of communication regarding blood test and staff sharing barcodes to perform blood test
16. Mrs E complains about aspects of the maternity and postnatal care and treatment she and her baby, received from the Trust in March 2024. Mrs E says the midwife used the term ‘sweep’ following a vaginal examination and the Trust provided inconsistent explanations around what this meant in its responses. Mrs E says this caused her to believe a sweep had occurred, which has caused her confusion and distress.
17. Mrs E also complains about the Trust’s actions regarding her baby’s blood test. She says staff failed to follow written instructions in badger notes, did not explain where they were taking her baby or what the test entailed and failed to document the test. She describes further distress by the Trust’s inability to confirm the identity of the staff member involved, who used another colleague’s barcode to perform the test.
18. Mrs E describes her entire experience at the Trust as traumatising. She says she has developed PTSD, lost all trust in the organisation, and sought 18 counselling sessions to cope and try and overcome what happened. She believes she will never forget what happened and feels saddened that staff cannot recall her care.
19. In the Trust’s written responses and during the local resolution meeting in March 2025, the Trust accept some failings in Mrs E’s case. This relates to its communication regarding the ‘sweep’ and the actions and lack of documentation of J’s blood test.
20. In the Trust’s first response, it says ‘a sweep can be performed after another sweep, but this should always be with consent. I am sorry this was not the case when you attended in labour’. In other parts of this response, the Trust suggest a sweep did not occur. In its next response, the Trust then say it has not been able to confirm if the midwife performed a sweep. It described the occurrence as a misunderstanding, due to the midwife using the term ‘sweep’ to describe her finger movements during the examination.
21. Having reviewed the Trust’s response, we understand why this has caused Mrs E confusion about whether the midwife performed a membrane sweep (a procedure used to bring on labour by separating the membranes of the amniotic sac from the cervix) without gaining consent. We recognise this has contributed to her distress.
22. Regarding the practice and lack of documentation surrounding J’s blood test, in the Trust’s responses dated October 2024 and April 2025, it accepts these actions fell below the standards it expected. The Trust acknowledged it is likely a member of staff used a colleague’s barcode when they performed J’s blood test.
23. We recognise the Trust has conducted an internal investigation and from this, it has not been able to confirm the member of staff responsible. We understand from what Mrs E has told us that the Trust’s inability to confirm who handled her baby and the sharing of barcodes has left her deeply unsettled and distressed by unanswered questions.
24. Our NHS complaints standards explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’ Further, it says we expect organisations to ‘take action to make sure any learning is identified and used to improve services.’ Our standards say organisations should be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’.
25. During our investigation, we asked the Trust to provide any actions or learning it has taken from Mrs E’s complaint. The Trust shared three actions plans it has implemented as a result of Mrs E’s complaint. We are satisfied the Trust has implemented several actions to learn from its mistakes and prevent similar occurrences happening again. These actions include:
Training:
• mandatory personalised care module covering choice, control, informed decision making, and cultural differences - for midwives, maternity support workers and obstetricians • mandatory BadgerNet training to ensure midwives, maternity support workers and obstetricians consistently document care on the electronic patient record • informed consent course delivered to 40 staff who work in maternity and neonatal care - this course covered topics such as legal consent, trauma-informed consent, emergency and antenatal consenting, how to support women and birthing people in decision making and consenting for refugees, asylum seekers and undocumented people • capillary blood sampling training which teaches midwives and maternity support workers safe and accurate blood sampling for babies and infants, led by an advanced neonatal nurse.
Tools and campaigns:
• launch of a local maternity and neonatal personalised care toolkit, which was co-produced with women, families, clinicians, and the maternity and neonatal voices partnership leads for use by pregnant people and clinicians • professional midwifery advocate (PMA) poster campaign, promoting advocacy support with personalised care planning in maternity care. This poster is displayed across both the inpatient and outpatient clinical areas and flagged to patients during their care • Mrs E’s suggestion of the Trust offering trauma informed advocacy is being supported by the PMAs.
Quality checks and reflective practice:
• weekly barcode access update sessions and spot audits of barcode access to prevent barcode expiry and/or barcode sharing • documentation audits conducted individually and annually • monitoring compliance of information governance (handling patient information safely and legally) training • practice observation, peer supervision, and team/individual reflective sessions focused on learning from Mrs E’s experience • on-going learning using complaints, incidents, claims, and engagement via the maternity and neonatal voices partnership to identify improvement opportunities • continued participation in the perinatal culture and leadership improvement programme – the aim is to assess culture, develop compassionate inclusive leadership strategies, and drive culture change • local maternity and neonatal system personalised care task and finish group to coordinate continued improvement work across the system • disciplinary threshold escalated to HR.
26. In response to Mrs E’s complaint, the Trust provided Mrs E with four written responses and held a resolution meeting with her. During the local resolution meeting, the Trust apologised for the confusion it caused by using the term ‘sweep’ and acknowledged a lay person would interpret this as meaning a membrane sweep.
27. The Trust also acknowledged its actions regarding J’s blood test and lack of documentation fell below the standards it expected. It apologised to Mrs E for the impact this caused. During this meeting, the Trust discussed with Mrs E the actions it has taken to investigate and learn from her complaint and was open to Mrs E’s suggestions.
28. We consider the Trust acted in line with our NHS complaints standards by acknowledging its mistakes and apologising for the impact Mrs E suffered. We recognise it has completed an internal investigation in relation to personnel matters, which we cannot legally investigate. The Trust also took Mrs E’s complaint as an opportunity to learn and improve its service. That said, we felt the Trust needed to do more to recognise the impact these events have had on Mrs E.
29. It is clear from what Mrs E told us, the experience she complains about, and reliving this during the complaints process continues to cause her significant amounts of distress. Mrs E told us she was struggling with this more now her counselling sessions have finished. We recognise this has been an extremely distressing time for her and we are sorry to hear she found it difficult to talk about her experience during our investigation.
30. As the Trust has acknowledged some failings in Mrs E’s case, we shared the impact Mrs E says these events have had on her and the outcomes she seeks by bringing her complaint to us. We recognise the Trust has implemented actions to address service improvements following Mrs E’s complaint and we are satisfied these actions should reduce the likelihood of these issues occurring again. We asked the Trust to consider Mrs E’s outstanding outcome of a financial remedy.
31. The Trust told us it has acknowledged the impact these events have had on Mrs E and will make a payment of £1,250 to recognise this.
32. Our severity of injustice scale helps us decide an appropriate amount of financial remedy, depending on the injustice the person has suffered. Importantly, our scale explains in cases where a person has experienced a distress lasting over 12 months or significant distress, lasting over three months, or which is ongoing we usually recommend a financial remedy between £1,250 to £3,700.
33. We do not underestimate the significant impact this experience has had on Mrs E. It is clear from what she has told us this continues to have a significant effect on her over 12 months later. We are satisfied the Trust has acknowledged and apologised for the mistakes it made and the impact this has had on Mrs E. The Trust has taken learning from the complaint and now offered a financial remedy, which is in line with our severity of injustice scale for the distress Mrs E told us about. This is in line with all the outcomes Mrs E wants by bringing her complaint to us.
34. We contacted Mrs E, to share the Trust’s offer of a financial remedy and asked for her comments. Mrs E accepted the financial remedy offered by the Trust to resolve her complaint.
Waiting in the PAU waiting room
35. During our initial call with Mrs E, she explained following her initial assessment she left the PAU to go for a walk and get some food due to room availability and irregular contractions. She says staff told her they would keep a room available for her but when she returned to the PAU, staff told her to wait in the waiting room. Mrs E describes during this time, she endured painful contractions in an open area surrounded by other pregnant women and their partners, which intensified both her physical discomfort and emotional distress. She describes this as a degrading experience and felt humiliated and stripped of dignity.
36. Mrs E says during the resolution meeting with the Trust in March 2025, the matron said the Trust did not follow its policy and it should keep a room available on the PAU for women in active labour.
37. In its response letter dated September 2024, the Trust say on initial examination Mrs E was 4cm dilated but her contractions were irregular. Therefore, staff assessed her as establishing into labour, rather than in active labour. The Trust say due to this and Mrs E’s preference for a room with a pool being unavailable at that time, it agreed a plan with her to go for a walk and to get some food from the canteen. On her return, there were no assessment rooms available. The Trust say as the PAU is an outpatient assessment and treatment area, it cannot hold rooms.
38. On review of the resolution meeting recording from March 2025, we heard the matron explaining Mrs E was 4cm dilated with irregular contractions therefore was establishing into labour, rather than in established labour. The matron then moved on to generically explain what the Trust’s considerations would be when dealing with a woman in established labour, including transfer to the birthing centre for one-to-one care. The matron also mentions the Trust’s maternity escalation policy. The Trust say it uses this to support safe maternity care.
39. During our investigation, we contacted the Trust to ask its opinion on whether it had acted in line with policy or guidance by asking Mrs E to wait in the waiting room upon her return to the PAU. We did this because we could not see it had been given an opportunity to respond formally to this matter.
40. In the Trust’s response to us, it explained a triage room is available on the PAU to complete initial triage assessment within the first 15 minutes for all attendances. A labour room is then allocated to women in established labour, following assessment and transfer from the PAU to the birthing centre.
41. The Trust explained it uses the Birmingham Symptom-specific Obstetric Triage System (BSOTs), which is a nationally adopted maternity triage tool, developed to improve safety and consistency in urgent pregnancy care. It also referenced a care of women in labour guideline which it uses to support clinical care and practice during confirmed established labour.
42. The Trust’s pregnancy assessment triage and escalation SOP includes the BSOTs tool. The BSOTs tool says an initial triage assessment should be completed within 15 minutes and assigns a priority colour that sets timings for further assessment. The highest priorities are red (to transfer to the birthing centre immediately) and orange (to transfer to a room on PAU and be seen within 15 minutes). This includes patients who need to be seen quickly because they have symptoms indicating serious concern or potential imminent delivery. The third priority is yellow. This is for patients with lower clinical risks such as mild pain, mild bleeding, or reduced or altered foetal movements. These patients should return to the waiting room and be seen within one hour. The lowest priority is green. This is for patients with minimal symptoms or risks. These patients should return to the waiting room and be seen within four hours.
43. The Trust’s care of women in labour guideline and maternity escalation policy, do not detail where a patient should wait following their initial triage when they are assessed as not in established labour. The care of women in labour guideline describes the latent phase of labour as the period before established labour where the patient may be experiencing irregular contractions, including dilatation up to 4cm. It says during this phase the patient may wish to continue this latent phase at home.
44. The Trust’s electronic records state that around 10.09am, midwives determined Mrs E was not in established labour, due to irregular contractions. The Trust assessed Mrs E as yellow on the BSOTs at this time. The Trust set out a plan which included going for a walk and getting some food from the canteen before returning for auscultation (a technique used to listen to the baby’s heartbeat).
45. The Trust say its electronic patient record does not note the time Mrs E returned to PAU from the canteen, so it cannot confirm how long Mrs E was in the waiting room before transferring to the birthing centre at 12.14pm. The Trust acknowledged a ‘breach of dignity’ for Mrs E while she waited in the waiting room. The Trust apologised for this in its response in September 2024.
46. We recognise a room would have given Mrs E more privacy and dignity when she returned to PAU with regular contractions. The Trust’s PAU triage and escalation SOP says patients assessed as yellow, which Mrs E was, should return to the waiting area. Therefore, we cannot see any indications the Trust did anything wrong when it asked her to wait in the waiting room following her return from the canteen. Due to this, we have not asked the Trust to consider a resolution on this specific matter.
47. We are sorry to hear Mrs E felt degraded, humiliated and stripped of dignity by this. The Trust has acknowledged this and provided an apology in its response letter.
48. We are satisfied the Trust has now taken (or agreed to take) appropriate action to resolve the majority of Mrs E’s complaint by apologising, taking action to improve services, and offering a financial remedy. We would like to thank both parties for their cooperation and understanding during this process.