14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If we see indications something has gone wrong, we consider the impact this had and any actions the organisation has already taken to put things right. Having done so, we consider that the Trust has already done enough to put right the impact of what went wrong.
15. Mrs C complains she had to wait hours for pain relief after every request during her labour. We understand Mrs C disagrees with some of what is written in the clinical records. As the clinical records were made at the time, we accept them as one source of evidence of what happened. We have also considered Mrs C’s account of the events.
16. When considering what should have happened, we referred to NICE guidance on induction, NICE guidance on pain relief in labour, and the BNF. We also considered the advice provided by our adviser.
17. NICE guidance on induction says staff should discuss with the woman the available pain relief options and provide pain relief in line with NICE guidance on pain relief in labour. It says this can include simple analgesia (such as paracetamol or codeine), labour in water and epidural anaesthesia.
18. One of the key points of NICE guidance on pain relief in labour is that staff should support the woman’s choice in deciding how she wants to cope with the pain in labour. It says staff should discuss the woman’s preferences and choices for care during labour and document these. NICE guidance on pain relief lists several options for pain relieving drugs including Entonox (gas and air), opioid injections such as pethidine or diamorphine, and epidural.
19. Mrs C attended an appointment with the Trust’s community midwives on 26 March 2024 to discuss her birth plan. This included consideration of pain relief options when it came time for the birth. According to the appointment notes, Mrs C said she would consider all forms of pain relief, including gas and air, paracetamol/codeine, opioid injections (such as pethidine, diamorphine, or Meptid), and an epidural.
20. On 18 April 2024 Mrs C attended the Trust as her waters had broken. She agreed to an induction of labour starting that night. The Trust first offered pain relief during the initial vaginal examination at 11.21pm, which the records say she declined.
21. At 11.31pm Mrs C buzzed for a midwife. She stated she was having a panic attack and the midwife noted she was visibly upset. The clinical records say the midwife discussed pain relief options going forward, as she had told staff about being scared of the pain and how rushed things felt. The records do not provide any further information as to what pain relief options were discussed.
22. Though we do not know exactly what pain relief options were discussed when the Trust induced Mrs C’s labour, we can see Mrs C was aware of (and open to) all pain relief options as discussed in the birth planning appointment.
23. On 19 April 2024 at 12.52am the midwife administered 1g paracetamol as requested by Mrs C because she was starting to feel cramps. At this point the clinical records also say Mrs C had declined codeine. Mrs C tells us she vomited the paracetamol back up. There is no documentation about this. At 1.15am a doctor prescribed codeine and a midwife administered this at 1.26am at Mrs C’s request.
24. Our adviser confirmed paracetamol and codeine are appropriate options for first line pain relief as set out in NICE guidance on induction of labour. Our adviser explained there is no specific guidance around the action to be taken if medication is vomited. It would be dependent on if the tablets were visible in the vomit. If they were visible then it may have been reasonable to check the individual medication information leaflet and discuss with a doctor whether the medication could be readministered. As this is not recorded within the medical notes, we are unable to say, even on the balance of probabilities, whether this should have happened. We recognise it will be disappointing to Mrs C that we cannot give a view on this.
25. At 1.42am the midwife discussed further pain relief options with Mrs C, including pethidine and a warm bath. Staff documented Mrs C actively confirmed that she was managing using breathing techniques. The clinical records say staff informed her to use the call bell if and when she needed further pain relief.
26. Over the next hour Mrs C found her tightening’s were increasing in strength and frequency. She requested additional pain relief. The records show staff prescribed pethidine at 2.45am and administered 100mg of this at 2.52am. It is not clear from the records nor Mrs C’s account what time she requested this pain relief. The clinical records document there was a delay in administering pethidine, though we do not know how long this was. The records say the midwife apologised for the delay and attributed it to the ward being busy. The records state the midwife was unable to locate the necessary staff to prescribe and check pethidine in line the local protocol. We recognise it would have been distressing for Mrs C to have to wait for pethidine when she was in pain.
27. Our adviser said the explanation for delay was reasonable, given that pethidine is a controlled drug it requires two staff to sign for its administration. Our adviser also explained there is no specific guidance that outlines acceptable time frames for pain relief being provided once requested during labour, but that this timeframe of at most 70 minutes did not seem unusual. Unfortunately, it not always possible to give controlled drugs like pethidine quickly. The drug first needs to be prescribed by a doctor or qualified prescriber, then staff need to obtain the single set of keys for the controlled drug cupboard, then two members of staff are required to administer and witness the administration. This can all take time.
28. At 6am the midwife noted Mrs C had been using gas and air intermittently and at 6.07am the Trust started to give Mrs C oxytocin (a hormone drip) to induce contractions. At 6.31am the midwife noted Mrs C said she would be keen for an epidural once she felt like she needed it. At 7.32am the records say Mrs C was asleep, managing to relax during contractions and coping well with gas and air. At 7.55am and 8.08am the records say Mrs C continued to feel the effect of pethidine and was calm.
29. At 9.11am a midwife administered a further 50mg dose of pethidine. It is not clear from the records nor Mrs C’s account what time she requested this. There is no evidence within the records that suggest staff discussed pain relief options in detail at this time with Mrs C.
30. Mrs C then asked for an epidural at 9.27am. An anaesthetist attended at 9.57am. We can see that the epidural initially failed, so a second anaesthetist attended at 10.54am, and the epidural started at 11.20am. We recognise the problems siting the epidural were distressing when Mrs C was in pain.
31. Following the epidural, we can see that Mrs C reported painless contractions and overall mild pain of which was reiterated in her assessments at 2.35pm, 3.30pm and 4.45pm. At 5.29pm Mrs C gave birth to her son.
32. We understand Mrs C’s view that because she received a lower dose of pethidine at 9.11am, she experienced unnecessary pain that impacted her decision to have an epidural.
33. Our advisor informed us the 50mg dose of pethidine was in line with national guidance. The BNF states for use in an obstetric setting the appropriate dosage is 50-100mg then 50-100mg after one to three hours if required, with a maximum dose of 400mg per day. Our adviser acknowledged that whilst 50mg is an appropriate dosage, it is not clear from the notes why the Trust decided to opt for a lower dose than it had given at 2.52am. Equally, it is evident this decision was not discussed with Mrs C, something the Trust acknowledges and apologised for within its response to her.
34. Our adviser explained that it would have been better practice for the Trust to have discussed Mrs C’s options with her. Despite the 50mg dosage being in line with guidance, a 100mg dose of pethidine might have offered Mrs C better pain relief at this stage, and the Trust missed an opportunity to discuss the dosage options with her. It is possible that if there had been further discussion the Trust may have agreed to a 100mg dose. It is possible Mrs C may have avoided requesting an epidural at this time if this had been effective.
35. We note there were eight hours passed between the 50mg dose of pethidine and Mrs C’s baby being born. We cannot say, even on the balance of probabilities, that she would not have gone on to request an epidural at a later stage in her labour even if she had been given 100mg pethidine at 9.11am. This is particularly the case given Mrs C said she was willing to be considered for an epidural during her birth plan on 26 March 2024, and reiterated this at 6.31am prior to the second dose of pethidine. As such, it would be impossible for us to make any connection between the lower dose of pethidine and the need for an epidural on the whole. We recognise Mrs C is in a position where she will never know if the epidural could have been avoided.
36. Through most of Mrs C’s labour, we consider the Trust managed her pain relief in line with NICE guidelines on induction and pain relief in labour. We recognise the differing doses of pethidine, and that a higher dose could have discussed with Mrs C at 9.11am. We cannot say, even on the balance of probabilities, that Mrs C would not have gone on to have an epidural at a later point. We can also see the Trust has already offered an apology for the lack of discussion about pain relief options, and that the 50mg dose of pethidine did not control her pain. We think this apology is a sufficient remedy for the fact Mrs C will never know if she could have had a different experience if the Trust had given 100mg pethidine on the second occasion. Therefore, we have decided to take no further action.