Antenatal period
23. Mrs E complains the Trust did not appropriately treat her pregnancy-induced hypertension during the antenatal period.
24. The Code says nurses must assess need and deliver, or advise on treatment, without too much delay. It also says nurses must respect the skills, expertise and contributions of their colleagues, referring matters to them where appropriate.
25. The NICE hypertension guidance defines hypertension as blood pressure of 140 mmHg systolic or higher, or 90 mmHg diastolic or higher.
26. For context, the lower number in a blood pressure reading is always the diastolic pressure. The diastolic pressure is the pressure when the heart rests between beats, and blood is pumped around the heart. Systolic pressure is the pressure when the heart pushes blood around the body. It is the higher number of the two.
27. The records show Mrs E’s antenatal plan as having blood pressure and urine checks every three weeks until 34 weeks. After this, BP and urine checks were to be completed every two weeks.
28. Our midwife adviser said that, as per the plan, the records show the Trust saw Mrs E at least every three weeks until 34 weeks. The Trust then saw her every two weeks until delivery. There is a gap over four weeks and one day between 12- and 16-weeks’ gestation, with no reason recorded for this delay.
29. The records also show that Mrs E had several unplanned attendances at the Trust with raised blood pressure.
30. On these appointments or when she presented to triage (on different dates), Mrs E’s initial blood pressure readings were:
• Gestation 29 weeks + 0 days – 143/85 mmHg • Gestation 32+2 – 148/87 mmHg • Gestation 33+1 - 144/90 mmHg • Gestation 34+3 - 142/89 mmHg.
31. When the Trust took further readings approximately an hour, or less than an hour later, our midwife and obstetric adviser says her blood pressure returned to within expected ranges:
• Gestation 29+0 – 129/79 mmHg • Gestation 32+2 - 127/81 mmHg • Gestation 33+1 - No abnormality detected • Gestation 34+3 - 137/86 mmHg.
32. The Trust’s actions here are both in line with the Code and the NICE hypertension guidance. The Trust increased its surveillance of Mrs E as it continued to measure her blood pressure until it returned to expected levels. The Trust provided care to Mrs E in a timely manner.
33. There are other days of note where Mrs E’s first reading of blood pressure was raised:
• Gestation 28+1 - 152/80 mmHg • Gestation 35+0 - 168/86 mmHg • Gestation 35+1 - 141/81 mmHg • Gestation 36+3 - 146/87 mmHg.
34. On each of these days, the records show the obstetric team, as well as the nursing/midwifery team, reviewed Mrs E. For the second and fourth bullet point especially, the Trust had taken multiple blood pressure readings which were all elevated.
35. The Trust also took blood and urine samples from Mrs E. The urine samples are used to determine the levels of protein in the blood, as this can be a sign of pre-eclampsia. We know already that the Trust had assessed Mrs E as being high-risk for pre-eclampsia.
36. The following actions occurred for each respective bullet point in paragraph 33:
• Gestation 28+1 - No further action required following obstetric review, and the Trust discharged Mrs E home. Blood pressure was 135/83 on discharge.
• Gestation 35+0 - The Trust discharged Mrs E home following an obstetric review, with a plan to return the next day for blood pressure monitoring, urine protein creatinine test (UPCR). It planned a further obstetric review for the next day. Blood pressure was 135/83 on discharge.
• Gestation 35+1 - No further action required following obstetric review. The Trust’s plan was to change to twice-weekly blood pressure monitoring.
• Gestation 36+3 - Following an obstetric review (including bloods, and UPCR), the Trust discharged Mrs E home. Her blood pressure had stabilised to 128/85.
37. The GMC’s Good Medical Practice says doctors must prescribe medication only when they are satisfied this meets the patient’s needs.
38. In terms of treating her high-blood pressure, our obstetric adviser explained Mrs E did not initially require any medication. This is because although Mrs E’s blood pressure appeared raised, it generally settled back to being within the normal range.
39. Our obstetric adviser continued to explain that no medication was needed until Mrs E was admitted to hospital, at which point her blood pressure had remained raised. The records show the Trust prescribed this and increased the dosage as required. Our adviser said the dosage and increases seemed appropriate.
40. We therefore think the Trust acted in line with the GMC’s Good Medical Practice, as it prescribed Mrs E with medication only when she needed it.
41. Overall, we can see the Trust’s actions here are in line with the NICE hypertension guidance and the Code. It increased surveillance of Mrs E when her blood pressure was elevated, especially on the occasions where there were continuous readings of elevated blood pressure. We can also see that the Trust provided this care in a timely manner, and that the nurses and midwives requested reviews from the obstetric team.
42. We understand the effect high-blood pressure had on Mrs E, and that this must have been uncomfortable and distressing for her. Overall, the records show the Trust monitored and treated Mrs E’s blood pressure frequently during the antenatal period. There are no failings here.
Inpatient monitoring
43. Mrs E complains the Trust did not appropriately monitor her whilst she was in hospital, prior to her planned induction.
44. The MEOWS system, outlined in the MEOWS guidance, helps for early recognition of the physical deterioration of women who are giving birth, or who are in the process of labour.
45. Where the MEOWS score is 0-1, staff should repeat MEOWS within 12 hours or earlier. If there are additional clinical concerns, a review should take place within an hour by the ward or on-call doctor.
46. Where the MEOWS score is 1-3, a doctor should review patients within 30 minutes, or a registrar on call if a doctor is unable to review. The MEOWS should be repeated between 30 and 60 minutes (one hour at most) until score returns to normal.
47. Where the MEOWS score is 4-5, the registrar on call should review patient within 30 minutes, or a consultant should review if a registrar is unable to. The MEOWS should be repeated within one hour at most and staff should continue to repeat MEOWS until score returns to normal.
48. The MEOWS guidance also says a MEOWS chart must be completed if there is a plan to admit the woman to the antenatal ward as an inpatient.
49. Mrs E attended the Trust in mid-August for her routine blood pressure and urine check, as well as for an ultrasound scan. The tests found Mrs E’s blood pressure was significantly elevated at 158/102, with protein in her urine. As a result, the Trust took her bloods and started her on medication to treat high blood-pressure.
50. The notes also report Mrs E had been reporting reduced foetal movement. The Trust planned to admit Mrs E to monitor her blood pressure, foetal movements, and to review for a planned IOL.
51. Having reviewed the records, there were occasions where the Trust monitored Mrs E in line with the MEOWS guidance. For example, the decision to admit Mrs E was during a review at 7.39pm. The Trust recorded a MEOWS score of 3 at 8pm. The next MEOWS score is 1 taken at 9.11pm.
52. Although the Trust took this MEOWS score one hour and 11 minutes later than the previous reading, it is not so far off an hour that we would consider it a failing.
53. Similarly, the next MEOWS score was 3 at 10.21pm – another hour and 11 minutes later. A doctor was called at 10.30pm. There was no answer by 11.02pm so a registrar was called to review. The Trust’s actions here are also in line with the MEOWS guidance.
54. However, there were more occasions where the Trust did not monitor Mrs E in line with the MEOWS guidance. For example, the day after admittance at 11.03am, Mrs E’s MEOWS score was 4. Based on this score, the MEOWS guidance says to contact the registrar for a review within 30 minutes (with escalation if not available). It also says to repeat MEOWS within one hour at most until score returns to normal.
55. The next MEOWS score is 3 taken at 1pm. This is two hours after the Trust took the previous MEOWS, when it should have been 60 minutes at the most. We cannot see in the notes if the registrar was called for a review. This is not in line with the MEOWS guidance.
56. There is a further example where Mrs E had a MEOWS score of 4 at 5.33pm. The next MEOWS score was taken at 7.06pm where Mrs E scored 3. Similarly, there is a delay of approximately one and a half hours between the MEOWS taken. We can see in the records an obstetric review took place before at 5.25pm, where the Trust decided to transfer Mrs E to the labour ward for IOL.
57. Overall, based on the evidence, we think the Trust did not monitor Mrs E in line with the MEOWS guidance. There are failings here. We will consider the impact of this below.
58. Our obstetric adviser says it is not possible to say if the gaps in monitoring Mrs E whilst an inpatient led to it affecting her ability to make decisions. Therefore, we cannot link this impact of the Trust not monitoring Mrs E as an inpatient, with the failing we found here.
59. We cannot see any clinical impact of the Trust not monitoring Mrs E in line with the MEOWS guidance. Mrs E claimed this lack of monitoring caused pounding headaches. Our obstetric adviser explains headaches are a common side-effect of pregnancy, and the high risk of pre-eclampsia was managed by expediting the delivery of her baby, which our obstetric adviser has said was the appropriate management.
60. In summary, we have found the Trust failed to monitor Mrs E in line with the MEOWS guidance. We acknowledge this may cause Mrs E further concern, but we hope she is reassured that there was no clinical impact of this.
Epilepsy medication
61. Mrs E complains the Trust did not administer her epilepsy medication when she was in hospital prior to her planned induction.
62. In the antenatal period, the epilepsy guidance says that women with epilepsy should be regularly assessed for adherence to AEDs (antiepileptic drugs). For intrapartum care, the epilepsy guidance says that AED intake should be continued during labour. If this cannot be tolerated orally, it should be administered in another way.
63. In terms of records keeping, Our Principles of Good Administration say organisations should create and maintain reliable records in line with recognised standards as evidence of their activities.
64. In the records we have received from the Trust, it is well-noted that Mrs E has epilepsy which requires medication (levetiracetam). Upon reviewing these records, we could not find a prescription chart for when Mrs E was in hospital in August prior to the birth of her baby.
65. We asked the Trust if it had this record. Despite conducting further searches, the Trust ultimately could not locate these prescription charts.
66. As per the epilepsy guidance, the Trust should have continued to prescribe Mrs E her epilepsy medication. In Mrs E’s discharge record, it says ‘patient’s medications were not reconciled during this admission’. Unreconciled medication means where a patient’s current medications have not been reviewed or updated.
67. The lack of prescription charts for Mrs E’s time in hospital is not in line with Our Principles of Good Administration.
68. Without the prescription charts, it is difficult for us to say whether the Trust administered her epilepsy medication. Furthermore, it is also difficult to say that even when Mrs E did receive her medication from her husband, whether this was also being managed by the Trust. The Trust have also not provided any comment, or us with any further information, to say that it did or did not administer or monitor Mrs E’s epilepsy medication.
69. Based on the evidence we have seen, we think it is likely there are failings here. We have considered the impact of this below.
70. Mrs E told us that she had to ask her husband to bring her epilepsy medication from home. Mrs E says it was inconvenient for her husband to bring her medication to the hospital. It also caused her worry not having her medication.
71. We understand how not having her regular medication for her epilepsy would have been worrying for Mrs E. We also acknowledge how it would have been inconvenient for her husband to bring her medication from home. We will outline how we propose the Trust put things right here toward the end of the report.
Consent
72. Mrs E complains the Trust performed a sterilisation procedure without her consent, and she says it did not provide enough time for her to consider this fully.
73. The Trust explained the records indicate it informed Mrs E about the option of a sterilisation procedure at the same time as the caesarean section, and that she provided consent for this. It continues to say that a further discussion took place whilst on the labour ward on the morning of the caesarean section, and Mrs E provided consent to undergo sterilisation.
74. The Trust has acknowledged that it discussed sterilisation very close to the birth, and this therefore gave Mrs E limited time to fully understand the implications of this decision.
75. Section 6.2 of the sterilisation guidance specifically covers sterilisation at caesarean section. It says if sterilisation is to be performed with a caesarean section, counselling should be given well in advance of the procedure.
76. As outlined in the background section, the Trust’s review of Mrs E on the morning of the IOL discovered the baby was in breech position.
77. A discussion took place between the midwife and Mrs E about the different options available. For example, to attempt to manually turn the baby from breech into headfirst position, or a caesarean section. Part of the note of this discussion says ‘[Mrs E] confident in wishing for [caesarean] and sterilisation’. It goes on to say ‘opportunity for questions given and answered’, however the notes do not explain further.
78. Following a review from an obstetrician, they note ‘…patient feels family is complete after this pregnancy and wants sterilisation. Patient expressed wish for c-section [caesarean]. Patient’s consent obtained for c-section and sterilisation’.
79. From the records we have, there is no other mention of sterilisation prior to the day of the delivery of the baby.
80. Our obstetric adviser explains the Trust should have discussed the possibility of sterilisation much sooner in the pregnancy to allow Mrs E to consider, and to discuss the option, with more time. We acknowledge the Trust only planned the caesarean section on the day Mrs E was due to be induced. However, we have seen no reason why the Trust could not have discussed possible sterilisation earlier with Mrs E.
81. We note Mrs E’s signature on the consent form, as well as what the Trust has written in the records. However, our obstetric adviser says this is not proof of properly informed consent, especially given the sterilisation guidance.
82. Based on the evidence, the Trust’s actions are not in line with the sterilisation guidance. The Trust only discussed the option of sterilisation with Mrs E on the morning of the caesarean procedure. As such, it did not provide Mrs E with reasonable time to consider this.
83. There are failings here. We will consider the impact of this below.
84. Mrs E said she would never have agreed to sterilisation as she and her husband were not ready to stop having children. This has been deeply upsetting and heartbreaking for Mrs E. She and her husband are still trying to conceive even though she acknowledges there is a very small chance it could happen. She says her mental health has worsened as a result, and that the decision to continue growing her family has been taken away from her.
85. It is difficult for us to say on the balance of probabilities as to whether Mrs E is likely to have gone on to have more children. What we can say, however, is that there was a loss of opportunity for Mrs E to fully consider her options. The option to expand her family has been taken away from her, regardless of whether she would have decided to have more children or not.
86. We can understand that the losing the choice about having any more children has been deeply upsetting for Mrs E and this has had a significant impact on her. We also understand how this has affected her mental health due to the choice of expanding her family being taken away from her.
87. The NHS Complaint Standards say organisations should openly identify instances when things have gone wrong and take responsibility for these.
88. The Trust has recognised that it should have discussed the options of sterilisation much earlier with Mrs E than what it did. However, it has not accepted responsibility for this and the implications of how it has now affected Mrs E.
89. In its complaint response, the Trust suggested it was reasonable to have asked Mrs E about this option. This was due to her already having ten children and underlying health problems.
90. We agree that asking Mrs E about this option was not unreasonable. The Trust’s rationale, that Mrs E has underlying health problems and a large family, existed through the pregnancy. We have seen no reason to suggest that Trust had to wait until discussing the caesarean section to also discuss sterilisation with Mrs E.
91. The main issue here is that the Trust did not follow relevant guidance in terms of giving Mrs E the time and space to consider this option. Especially as it is a permanent type of contraception.
92. We think the Trust can do more to put things right for Mrs E. Especially considering the lasting impact this has had on her. We will outline our recommendations below.