12. Mrs P says the Trust did not communicate her birth plan with all relevant teams ahead of her planned C-section in August 2024. She says this meant when she attended the Trust for her procedure, she was questioned by the Trust’s staff about why she was having a C-section. We are sorry hear she feels like the Trust let her down, as she told us she had been led to believe the Trust had compassion for her personal circumstances and would support her.
13. She also complains it did not provide her with clear information when it identified her son had a heart murmur during his newborn checks. She says it did not explain what causes a heart murmur, what follow up should be carried out, any signs she should look out for and whether it could be serious. Understandably, this was a concerning time for her and her husband, as she told us they had to take their son to the emergency department shortly after it discharged them. Mrs P explained the following days were very traumatic for them whilst her son received treatment for a blocked artery.
14. Our Principles for Remedy say we would expect organisations to acknowledge mistakes and apologise for the impact these mistakes had. The remedy should be appropriate and proportionate to the injustice sustained and consider the wishes and needs of the complainant in deciding an appropriate remedy.
15. In the Trust’s response to Mrs P’s complaint, it explained that the peri-operative team who admitted her in preparation of her C-section were not aware of her birth plan. A peri-operative team is a group of healthcare professionals who are involved in care before, during and after surgery.
16. It explained in relation to her complaint it was reviewing its internal processes to ensure the maternity service can best support women’s personalised care plans. It also apologised for the distress she experienced.
17. The Trust also explained that during Mrs P’s son’s newborn check in August it detected a heart murmur and escalated this to the neonatal team. It says it carried out blood pressure checks which it reported as satisfactory, at the time. However, it acknowledged that the blood pressure checks it carried out did not meet its expected standards and apologised for this. It explained it fed back her experience to the staff involved.
18. During our conversations we discussed with Mrs P what the Trust had already done to address her concerns and what further she wanted to achieve from bringing her complaint to the Ombudsman. Mrs P explained she wanted the Trust to explain what improvements it has put in place to prevent the same thing happening to someone else.
19. We contacted the Trust to ask for some further clarification. It explained its peri-operative team who admitted Mrs P, are now included in the information sharing process to prevent the same thing from happening again. This shows the actions the Trust has taken to include all relevant teams in its information sharing process to improve its service based on Mrs P’s complaint.
20. We are reassured it should communicate better and make all relevant teams aware of women’s personalised plans and circumstances going forward, to prevent the same thing from happening again.
21. The Trust also said the neonatal team has introduced further training on the importance of clear communications with parents to ensure they understand, are fully informed, and aware of what tests are being carried out on their child. It said it will continue to audit this over the next few months.
22. The Trust has identified it did not clearly communicate with Mrs P at the time of events. We are pleased to see the Trust has taken specific action to improve its communication with parents, in response to Mrs P’s complaint.
23. It has also informed us it will put this information and explanation in writing to Mrs P. This shows the Trust has listened to Mrs P’s concerns. It appears it has taken action to ensure its staff are aware of her concerns and provided staff with additional training to improve its communication to prevent anyone else experiencing the same thing Mrs P experienced.
24. Based on the information we have seen it appears the Trust has acknowledged where its service fell below its usual standard and apologised for the impact this had on Mrs P. We can see it has provided information to explain the actions it has taken, since Mrs P’s complaint, to address its findings. It has also agreed to send its further explanation in writing to her, which is in line with what she told us she wants to achieve, and Our Principles for Remedy.
25. We are satisfied that the actions the Trust has taken since Mrs P raised her complaint and its agreement to provide her with an explanation of its actions, achieves the outcome she is seeking. Therefore, there does not appear to be any actions left outstanding for the Trust to remedy.
26. The Trust carried out these actions to improve its service in response to the complaint Mrs P raised. We hope this reassures her the Trust has taken her complaint seriously and will take comfort in the steps it has taken to prevent the same things from happening to someone else.