5 April
15. Miss Y complains that on 5 April, midwife 1 dismissed her concerns about pain and low foetal movement and sent her home.
16. The Trust apologised for any miscommunication, and for if midwife 1 made Miss Y feel encouraged to go home. The Trust said it has fed this back to midwife 1, and detailed the steps it has taken to learn from this within the department.
17. Miss Y’s records say she attended the Trust on 5 April as she had reduced foetal movement for the second time, and a two-day history of back pain. The notes say the plan was for a doctor to review Miss Y, but she self-discharged as she did not want to wait. The notes say midwife 1 explained the risks involved to Miss Y, and that leaving was against medical advice.
18. We recognise Miss Y says midwife 1 encouraged her to go home as there were long waiting times, whereas the records indicate they encouraged her to stay. We do not dispute either party’s recollection of events. As we were not there, we cannot say with any certainty what happened during this interaction that day. While the Trust has apologised for any miscommunication and for how midwife 1 made Miss Y feel, it has not specifically said they gave her the wrong information.
19. In the absence of any further corroborating evidence, we are unable to form a view on whether midwife 1 told Miss Y to go home. While this means we cannot say for sure that midwife 1 did not, it also means we cannot say for sure that they did. As a result, we cannot find a failing in the Trust’s actions here. We recognise this is a frustrating outcome.
7 April
20. Miss Y complains that on 7 April, midwife 2 dismissed her concerns about pain and bleeding when she called the Trust.
21. The Trust apologised for midwife 2 telling Miss Y to stay home, when they should have advised her to come to the Trust for a review. The Trust said it has fed this back to midwife 2, and detailed the steps it has taken to learn from this within the department.
22. Miss Y’s records contain evidence of a telephone consultation with midwife 2, but there are no notes detailing what either party said.
23. While there is no record of this conversation, there is no disagreement between Miss Y and the Trust as to the advice midwife 2 gave during this telephone consultation. The Trust have acknowledged the advice midwife 2 gave was wrong. We understand how upsetting this can be.
24. We have seen midwife 2 told Miss Y to stay home when they should have advised her to come in for a review that day. We consider this to be a failing. We will consider the impact of this later in the report.
8 April
25. Miss Y complains that on 8 April, midwife 1 dismissed her concerns about pain and a feeling of pressure in her birth canal. Miss Y believed the feeling of pressure was her baby’s head.
26. The Trust apologised that midwife 1 ignored Miss Y’s concerns about the pain and pressure she was feeling. The Trust said staff should have questioned Miss Y’s presentation and escalated her to the obstetric team due to the possibility of threatened or preterm labour and apologised this did not happen. The Trust said it has fed this back to staff, and detailed the steps it has taken to learn from this within the department.
27. Miss Y’s records detail an obstetrician reviewing her at around 1.30pm on 8 April. The outcome of this review was that the Trust would admit Miss Y to a ward and monitor her for at least 24 hours. The notes from the ward staff afterwards detail Miss Y complaining of mild pain, and the Trust offering paracetamol which she accepted.
28. There is no mention in Miss Y’s records of her alerting staff to a feeling of pressure in her birth canal, but the Trust have still apologised it ignored her concerns about this. The Trust have acknowledged it should have referred Miss Y to the obstetric team due to her ongoing pain, and her losing her show (the bloody mucus which plugs the cervix during pregnancy). We recognise how distressing it can be when your concerns are not being taken seriously. The loss of her show is documented in the records as happening at 9.40pm. Another midwife had taken over Miss Y’s care from midwife 1 at this point.
29. We have seen the Trust did not refer Miss Y to the obstetric team as it should have that evening. We consider this to be a failing. We will consider the impact of this later in our report.
9 April
30. Miss Y complains that on 9 April, the gynaecologist did not perform any examinations or tests and just told her she was suffering from placental abruption, so she would haemorrhage, and her baby would be still born.
31. The Trust acknowledged that the gynaecologist should have performed an internal examination on Miss Y, but did not directly address her concern about what she alleges they said to her. The Trust said it arranged a meeting and teaching session with the gynaecologist as a result of Miss Y’s case.
32. Miss Y’s records detail her interactions with her midwife that day. Miss Y reported further bleeding, and pain which she felt needed stronger relief than the paracetamol she had been taking. The gynaecologist saw Miss Y at 5.02pm and took a history from her, including at looking at the photos on her phone of her blood and mucus loss. The notes say the gynaecologist asked for Miss Y to be canulated and admitted to the labour ward due to antepartum haemorrhage (APH). There is no evidence in the records that the gynaecologist performed a physical examination or tests on Miss Y.
33. APH is bleeding from the genital tract after 24 weeks of pregnancy, but before birth. APH can be minor or major, and can have various causes (including, but not limited to, placental abruption). Miss Y was haemorrhaging, but there is no evidence in the records that the gynaecologist told her she was suffering from placental abruption, or that her baby would be still born.
34. There is a clear discrepancy between Miss Y’s recollection of this interaction, and what the Trust recorded in her notes. We do not dispute Miss Y’s recollection, and have not seen anything which would suggest the Trust’s records are inaccurate. As we were not there, we have no way to say for certain what the gynaecologist said.
35. We consider we do not have enough corroborating evidence to form a view on whether the gynaecologist told Miss Y that she was suffering from placental abruption, or that her baby would be still born. While this means we cannot say with a reasonable degree of certainty that the Trust did not say this, it also means we cannot say it did. As a result, we cannot say there is a failing in the Trust’s actions here. Again, we recognise this is a frustrating outcome. While we cannot consider what the gynaecologist said any further, we can still consider their actions.
36. The Trust have acknowledged the gynaecologist should have performed an internal examination on Miss Y. This is in line with NG25 which says, ‘Offer a clinical assessment to women reporting symptoms of preterm labour who have intact membranes [their waters have not yet broken]. This should include: • clinical history taking • the observations described for the initial assessment of labour in NICE's guideline on intrapartum care • a speculum [a tool used to look inside the vagina and see the cervix] examination’.
37. We have seen the gynaecologist did not perform an internal examination on Miss Y as it should have that day. We consider this to be a failing. We will consider the impact of this below.
Impact
38. Miss Y says as a result of the Trust not delaying her labour, her son suffered from a hernia and laryngomalacia, because he had not had long enough to develop.
39. We have identified failings in midwife 2 telling Miss Y to stay home on 7 April, the Trust not referring her to the obstetric team in the evening of 8 April, and the gynaecologist not performing an internal examination on 9 April.
40. The medical use of drugs (tocolytics) to temporarily stop premature labour and delay birth is called tocolysis. NG25 says, ‘Take the following factors into account when making a decision about whether to start tocolysis: … • other clinical features (for example, bleeding or infection) that may suggest that stopping labour is contraindicated’.
41. The Trust’s examination of Miss Y in the afternoon of 8 April showed she was not in active labour. Our adviser told us this means the Trust would have observed the same if it had examined her the day before. As Miss Y was not in premature labour at the time, there was no indication to administer tocolysis to temporarily stop this.
42. Miss Y’s records detail that she had bleeding throughout the time period we are considering. Our adviser explained tocolysis is contraindicated when there is bleeding due to the chance it is being caused by placental abruption, which could worsen with tocolytic medication. This means it would not have been appropriate, in line with guidance, for the Trust to initiate tocolysis at any point during this period. We recognise this contradicts what the Trust has said in its response.
43. Our adviser told us that as the gynaecologist did not perform an internal examination on 9 April, it is likely they overlooked an earlier diagnosis of active labour. There is also a possibility this may have been diagnosed if the Trust referred her to the obstetric team in the evening of 8 April. However, as previously discussed, it would not have been appropriate for the Trust to delay Miss Y’s labour even if this had happened. We therefore cannot link these claimed impacts to the Trust’s failings we have identified.
44. Miss Y says she struggled with depression and anxiety, which meant she was unable to breastfeed or bond with her son, and she has concerns about accessing healthcare in the future.
45. We have identified failings in midwife 2 telling Miss Y to stay home on 7 April, the Trust not referring her to the obstetric team in the evening of 8 April, and the gynaecologist not performing an internal examination on 9 April.
46. Our adviser told us Miss Y likely would have found reassurance in the Trust telling her she was not in active labour if she had come in on 7 April. The psychological impact of the preterm birth also would have been less if Miss Y had more warning about it or felt listened to by staff. We recognise this will have caused Miss Y to have concerns about accessing healthcare in the future. We hope the Trust’s acknowledgement of its mistakes and actions it has taken to improve its service have provided Miss Y with some reassurance about this.
47. Miss Y’s GP records indicate she first contacted the Practice about her difficulties in breastfeeding in June 2024 and mentioned the birth had been traumatic. In January 2025, Miss Y reported she had been suffering with anxiety and depression for the last two months. The Practice prescribed mirtazapine (an antidepressant) for Miss Y as a result of this consultation.
48. We need to consider that a large contributing factor to Miss Y’s mental state after the birth of her son would have been him being born prematurely and having a hernia and laryngomalacia. We have seen we cannot link the premature birth, and therefore these health conditions, to the failings we have identified. We cannot say that Miss Y would definitely have not suffered from depression and anxiety following the birth of her son, even if the Trust had made no mistakes. We therefore also cannot say Miss Y would definitely have not struggled with breastfeeding or bonding with her son.
49. We do recognise the failings we have identified would have contributed to her mental state and caused additional distress at what was already a difficult time. We can also say it likely had some impact on her ability to trust in NHS services. We therefore can partly link these claimed impacts to the Trust’s failings we have identified.
Outcomes
50. One of the outcomes Miss Y wants is for the Trust to implement service improvements.
51. In the Trust’s response it has acknowledged the failings we have identified, and set out the steps it has taken to reduce the risk of mistakes like those happening again. Having thoroughly considered the steps the Trust has detailed it has taken, we have decided we do not consider the Trust needs to implement any further service improvements to address the failings we have identified.
52. Miss Y is also looking for a financial remedy as an outcome.
What the organisation should do
53. Our Standards say to put things right, organisations should consider providing financial compensation for direct or indirect financial loss, loss of opportunity, inconvenience, distress, or any combination of these.
54. When deciding on a level of financial remedy, we use our guidance on financial remedy to guide what we may ask an organisation to provide. This includes both our severity of injustice scale, and information on how to consider cases where we have made similar recommendations.
55. Having considered all of the information available, we recommend the Trust pays Miss Y £200 to recognise the additional unnecessary distress its mistakes caused her. We ask the Trust to do this within one calendar month of the date of our report.
56. This ends our report.