22. We will address each element of Mrs K’s complaint separately for clarity. Where a complaint element is closely related to another, we will address them collectively.
Obstetrician’s information 23. Mrs K tells us the obstetrician gave her incorrect information around the risk factors involved in a vaginal breech birth. She said an internet search showed this information to be inaccurate.
24. The Trust said its clinicians gave Mrs K the correct information at her antenatal appointments in January and February 2024.
25. Section 4.1 of RCOG breech guidance sets out key information clinicians should discuss with patients who present with a breech baby at term.
26. We can see an obstetrician discussed the risk factors around vaginal breech birth with Mrs K on 8 February. During this appointment, we can see the obstetrician discussed the key risks associated with vaginal breech birth, including: • still birth (when a baby is born dead after 24 weeks of pregnancy) • eahead entrapment (when the baby’s head becomes stuck in the birth canal) • foetal hypoxia (when the baby does not receive enough oxygen) • arrest in labour (a complete halt in the progress of labour).
27. The risk factors set out above, overall, appear to mirror what is recommended in RCOG breech guidance.
28. Our obstetrician adviser said the only risk factor discussed that day that they would disagree with concerned ‘risk of cerebral palsy if hypoxia’. They note there is little clinical evidence to support this risk factor.
29. We acknowledge the obstetrician’s advice included one risk factor which is not altogether supported by clinical evidence. We recognise it caused Mrs K some frustration.
30. We are persuaded the advice given to Mrs K is, overall, in line with guidance as we have set out above.
31. The advice linking hypoxia to cerebral palsy is something we think the obstetrician should perhaps have omitted from their advice, but we do not think this mistake means their overall advice is so far below what we would expect to see that it warrants a failing. We therefore view it as a shortcoming.
32. We also understand Mrs K did an internet search following the obstetrician appointment which found the advice was not wholly accurate.
33. While we appreciate this may not have altogether eliminated Mrs K’s frustration, we expect it will in the very least have provided some reassurance around the risk factors she discussed with the obstetrician and avoided any lasting doubt.
34. As we have seen no failings, we have decided to take no further action in this part of Mrs K’s complaint.
Withdrawal of home birth support 35. Mrs K said the Trust changed its mind 38 weeks into her pregnancy and decided not to support her home breech birth. She said the Trust reached this decision despite supporting her home birth at 32 and 36 weeks (when the baby was known to be breech positioned).
36. The Trust said Mrs K attended the antenatal clinic on 2 January 2024 (when she was 32 weeks plus four days pregnant). It said its obstetrician discussed Mrs K’s home birth plan and advised that home birth was not always achievable due to demands on the Trust’s maternity unit and its staffing levels.
37. It added Mrs K’s baby continued to be breech positioned and midwives visited her home on 30 January (when she was 36 weeks plus four days pregnant) to further discuss her birth plans.
38. It said during this meeting the midwife explained that a member of staff may not always be available to support her home birth. They noted that if this happened, she would need to be transferred to the hospital’s birthing centre.
39. The Trust’s maternity guidance describes how to support women’s choices if they choose to deviate from the standardised antenatal (pregnancy), intrapartum (labour and delivery) and postpartum (post childbirth) care.
40. This guidance says, ‘women who choose to deviate from standardised guidance at booking or at any stage of their pregnancy, will be advised to meet with the community manager and/or the antenatal outpatient manager to discuss their care and birth options.’
41. We can see Mrs K discussed her concerns with the Trust’s midwifery team in January and February. During these exchanges, we can see midwives and the Trust’s divisional midwifery and nursing director clearly set out that they would support Ms K’s home birth, but this carried risk, and any support would depend upon availability of its staff at the time.
42. We acknowledge Mrs K specifically highlighted the home visit at 38 weeks where she said the midwife’s conduct was unacceptable. We will specifically focus upon this allegation in the next section of this statement.
43. Having reviewed the available evidence, we are satisfied, overall, that the Trust handled its messaging around Mrs K’s home birth plan in line with its maternity guidance.
44. We can see no indication the Trust’s midwifery team changed its mind or withdrew home birth support. Instead, it attempted to manage Mrs K’s expectations about the risks involved in home breech birth and its ability to provide home midwifery support throughout her labour.
45. It clarified such risks and a lack of available staff could result in her being transported to the Trust’s birthing centre.
46. For the reasons set out above we have decided to take no further action in this part of Mrs K’s complaint.
Home visit at 38 weeks and misinformation around ECV 47. Mrs K said a midwife insisted on a home visit at 38 weeks. She said the midwife proceeded to withdraw home birth support during this visit without empathy and disregarded her ADHD diagnosis.
48. She adds that the midwife also gave inaccurate information concerning ECV. She said the midwife told her that she was ‘too far along’ in her pregnancy for ECV to work. ECV is where clinicians turn a baby from a breech to a head-down position.
49. The Trust said it can see Mrs K attended an antenatal clinic appointment at the hospital on 8 February when she was around 38 weeks pregnant. It said the midwife offered ECV during this clinic, but she declined. It said there was a home visit booked for the next day but there was no documentation to indicate they discussed ECV further.
50. Part 1.1 of NMC guidance says midwives should treat people with kindness, respect and compassion.
51. We asked the Trust if it had any documentation around a home visit on 9 February. It said it cannot find any records of this home visit.
52. Having carefully considered this element of Mrs K’s complaint, we are persuaded by her account that the midwife may have disregarded her ADHD diagnosis and provided information without appropriate empathy. We have no reason to doubt what she has told us.
53. We recognise discussion about her birth options in the lead up to her due date will have been very important to her. We also appreciate it will have been important for Mrs K to know the midwife recognised her ADHD diagnosis and delivered any information sensitively.
54. We think the way this was discussed led to some avoidable upset and frustration. This emotional impact was experienced at the time and was not long lasting. We therefore see the injustice is at level two in our severity of injustice scale.
55. Our severity of injustice scale contains six different levels of injustice that a complaint could fall into, which increase in severity. The more severe the injustice means an increase in the remedial action we think will put it right.
56. We think an acknowledgement of what went wrong alongside an apology is proportionate to put right what went wrong.
57. During the complaints process, we can see the Trust acknowledged the midwife’s actions likely left Mrs K feeling unsupported. It stopped short of giving her an apology.
58. We asked the Trust whether it would be willing to provide an apology to Mrs K. It agreed to write to Mrs K to acknowledge and apologise for what went wrong. This means this matter has been put right and there is nothing left for us to explore.
59. The midwife may not have communicated overall with Mrs K in line with applicable guidance. That said, we are unable, even on balance, to reach a view they gave inaccurate information about ECV during the home visit on 9 February. This is due to a lack of evidence about what was discussed at that time.
60. We hope, however, that the Trust’s willingness to acknowledge the emotional impact its midwife’s communication had upon Mrs K and its apology allows her some closure in these matters.
61. We have decided to take no further action in this part of Mrs K’s complaint.
Independent midwife support and external referral 62. Mrs K said the Trust did not explore whether an independent midwife could support her home breech birth. She also said the Trust did not refer her to an external organisation for breech birth support.
63. The Trust said its policies do not include independent midwifery support or referral to an external organisation, so is not a service it could have offered.
64. Our Principles say public bodies should follow their own policy and procedural guidance, whether published or internal.
65. We reviewed the Trust’s maternity guidance. There is no provision for it to supply an independent midwife, nor is there any provision for it to refer to an external organisation.
66. We also recognise Mrs K made some separate enquiries with a nearby NHS Trust to see if it could support her birth choices. We understand this nearby NHS Trust declined Mrs K’s request as she fell outside of its catchment area.
67. Based on the information we have seen, there is nothing to indicate the Trust did anything wrong here. We think it acted in line with our Principles.
Home birth support 68. Mrs K said the Trust informed her a rota would be in place to support her home birth covering the two-week period after her due date. She said that despite this, midwives were not available to support her throughout her home labour.
69. This meant she started labour at home but had to transfer to the Trust’s birthing centre. Mrs K is frustrated midwives failed to give her advanced warning that they would not be able to fully support her home birth.
70. The Trust said that owing to pressures on its midwifery service it was not possible to work the rota it had agreed with Mrs K. It said such pressures can occur at short notice due to the unpredictable nature of other patients going into labour.
71. NMC guidance sets out how nurses can provide good care. Section 2.1 says nurses must work in partnership with people to make sure they deliver care effectively.
72. Our Principles say public bodies should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case.
73. We can see a midwife explained to Mrs K at around 4.25am on 3 March that their shift was coming to an end and that there was no cover to take over. They let Mrs K know they would arrange an ambulance to take her to the Trust’s birthing centre.
74. We have seen no evidence to indicate the midwives knew of the pressures on its midwifery service at an earlier stage and withheld this information from Mrs K.
75. We think the Trust’s explanation (set out at paragraph 70) is plausible. Maternity care has been under considerable pressure in recent years, and it is not inconceivable that the Trust’s midwifery team encountered unexpected pressures early on 3 March which meant it was unable to further support Mrs K’s home birth.
76. It is also important to reiterate here that staff did attempt to manage Mrs K’s expectations about its ability to fully support her home birth. A key factor it raised was the availability of its midwifery staff.
77. We are satisfied that Trust staff acted in line with both our Principles and NMC guidance. They provided what support they could to facilitate Mrs K’s home birth but when resources where no longer available, staff promptly discussed this with Mrs K alongside transfer to hospital.
78. We recognise this must have been a very distressing experience for Mrs K and her partner as it is not what they wanted or had planned for. We hope our statement provides some reassurance around this matter.
Colostrum 79. Mrs K tells us when she transferred to hospital on 3 March the midwife failed to refrigerate her supply of colostrum which she had collected over several weeks. She said she lost her entire supply of colostrum.
80. Mrs K said this led to considerable distress once the baby was born as she struggled to feed her baby and had no backup supply.
81. Colostrum is the first milk produced during pregnancy ahead of giving birth. It is high in calories, antibodies and stem cells which means it supports the baby’s immune system and development. Colostrum can also help to establish breastfeeding.
82. The Trust acknowledged it made a mistake during the complaints process and apologised to Mrs K for its error and any distress this may have caused. It added that it had reminded the wider midwifery team to ensure colostrum is always refrigerated to prevent something similar from happening again.
83. Section 1.2 of NMC guidance says midwives must deliver the fundamentals of care effectively. Fundamentals of care include nutrition and hydration and providing help to those who are unable to feed themselves or drink unaided. We see this is relevant to this section of Mrs K’s complaint.
84. We agree there is an indication of a failing here as midwives did not act in line with NMC guidance.
85. We acknowledge the loss of the colostrum likely caused Mrs K some lasting upset and distress at an already challenging time.
86. With this in mind, we can see the emotional impact caused by the loss of the colostrum was primarily felt following the birth of Mrs K’s daughter on 3 March. We recognise this upset and distress may have lasted for several months following the birth. We can therefore see Mrs K is at level two of our severity of injustice scale.
87. We think further remedy is proportionate here to fully put right the impact of what went wrong as we do not think an apology alone is sufficient.
88. The Trust has agreed to provide Mrs K with a financial remedy to help put this matter right. We will discuss this in more detail at the end of our statement.
89. We also discussed what service improvements the Trust had put in place.
90. The Trust said this incident was likely discussed with staff at its daily huddles. The Trust said these huddles are not recorded, and due to it taking place around two years ago it cannot supply us with evidence. It did, however, provide us with a ‘complaints feedback and learning’ bulletin which it created in response to this incident.
91. We can see this ‘complaints feedback and learning’ bulletin described what happened and what learning staff should take from it. It also describes what staff should do in relation to colostrum storage and how staff should provide feeding support to patients.
92. We are satisfied the ‘complaints feedback and learning’ bulletin alongside the financial remedy (which we will discuss in more detail at the end of our statement) is sufficient to put right the impact of what went wrong here.
93. We are pleased the Trust is willing to provide further remedy following our intervention. Having carefully thought about this, we do not see there is anything left for us to look at. We have therefore decided to take no further action in this part of Mrs K’s complaint.
Midwives entering the room during labour 94. Mrs K tells us the Trust promised she could have a private room at its birth centre where she would not be disturbed. She said the Trust later contradicted this when it told her a midwife would have to enter the room every 30 minutes to check on her.
95. The Trust apologised if Mrs K had been given conflicting information but said it was standard practice to have a midwife present in some capacity as this would ensure Mrs K’s and her baby’s safety.
96. Sections 16.1 to 16.3 of NMC guidance set out that midwives must act without delay if they think there is a risk to patient safety.
97. We can see the Trust’s divisional midwifery and nursing director emailed Mrs K on 21 February 2024 in response to her birth plan. The midwifery and nursing director apologised that staff had not broached this subject at an earlier stage and explained why it was important for midwives to periodically check in on her during labour.
98. The divisional midwifery and nursing director’s email is very detailed and references relevant guidance and legal precedent to support their rationale for having a midwife present during labour.
99. It clearly sets out what options were available to Mrs K in terms of where she had her baby and what support it would provide.
100. We recognise there appears to have been some miscommunication at an earlier stage in Mrs K’s birth planning. The divisional midwifery and nursing director put this right by very sensitively acknowledging Mrs K’s concerns around her birthing options and at the same time very clearly managing her expectations about what was or was not possible.
101. Our midwife adviser said all patients in established labour should receive supportive one to one midwifery care. This means not leaving the woman on her own except for short periods or at her request (which should also only be for short periods).
102. Based on the evidence we have seen, we are satisfied the Trust acted in line with NMC guidance. We have decided to take no further action in this part of Mrs K’s complaint.
Midwife’s advice 103. Mrs K said a midwife told her she was 9cm dilated and some of her cervix was in the way. She said the midwife told her not to push, despite a strong urge to do so.
104. Cervical dilation is the process by which the cervix (the lower part of the uterus) opens to allow the baby to move from the uterus to the birth canal. It is measured in centimetres, from 0cm (completely closed) to 10cm (fully dilated).
105. Mrs K tells us this intervention was contrary to her birth plan which stated she did not want guidance on pushing and this slowed her labour.
106. The Trust said it is normal practice to encourage a woman to breathe through contractions when the cervix remains present. This is because pushing into the cervix can cause it to become swollen and delay progression to full dilation.
107. NMC guidance, sections 2 to 2.6 and 4 to 4.2 describe the importance of clear communication when providing care. These sections note midwives should balance the needs of the patient and their preferences for care alongside providing effective care, advice and guidance.
108. Our midwife adviser said it can be harmful for a woman to push on the cervix. They told us this can have detrimental consequences including altercation to circulation and increased perineal trauma (the area between the vaginal opening and the anus) alongside long-term effects on bladder function and pelvic floor (a group of muscles at the base of the pelvis) health.
109. Our midwife adviser adds that this advice would not have slowed Mrs K’s labour but would have prevented any associated risks of baring down on her cervix.
110. Based on what we have seen, we see no indication anything went wrong. The midwife correctly intervened when they saw there was good reason and this is in line with NMC guidance.
111. We appreciate Mrs K will likely have been upset by the midwife’s intervention which deviated from her birth plan. We hope our statement has provided her with some reassurance that there was good reason for this intervention.
112. We have decided to take no further action in this part of Mrs K’s complaint.
Delivery of the placenta 113. Mrs K tells us that following birth a midwife commented she had lost a lot of blood. She said the midwife offered an injection as she was at risk of further bleeding. Mrs K explains she was afraid and consented.
114. After the injection, she said she wanted a natural delivery of the placenta, but the midwife said this was not possible and this meant medical staff needed to remove it.
115. The placenta is a temporary organ that forms in the uterus during pregnancy. It plays a vital role in providing nutrients and oxygen to the foetus and removing waste products.
116. Mrs K said the midwife did not explain what effect the injection would have upon her birth or give her any choices afterwards.
117. The Trust said it recorded a ‘gush’ of blood which was possibly due to the separation of the placenta and in total it recorded Mrs K had lost 1370mls of blood. It said this represented significant blood loss and necessitated immediate action.
118. RCOG haemorrhage guidance sets out how medical staff can prevent and manage postpartum haemorrhage (PPH).
119. NMC guidance set out at paragraph 107 is also relevant here.
120. We recognise Mrs K wanted no intervention during her birth. This is reflected in her medical records which indicate a ‘physiological first stage’ approach, which means there was no intervention during the initial stages of her labour.
121. At 2.08pm we can see an entry in the medical records which noted Mrs K was suffering a PPH following the birth of her child.
122. Our obstetrician adviser said it is not uncommon for a woman to bleed following birth, but this must be treated promptly, as prolonged heavy bleeding can lead to serious complications.
123. Our obstetrician adviser explains that in order to treat a PPH the midwife will need to deliver the placenta as a priority. Once the placenta is removed, this will allow the uterus to contract and allow for more control of the bleeding.
124. We can see the midwife was concerned about Mrs K’s bleeding and offered ‘active third stage management’, which Mrs K accepted. This management consists of an ergometrine-oxytocin injection.
125. Our obstetrician adviser said this is routinely given to women following delivery of the baby unless it has been specifically refused. This injection assists with the delivery of the placenta. Our obstetrician adviser notes that Mrs K had lost quite a lot of blood by this stage, and it was correct for the midwife to be concerned, offer management and quickly treat the PPH.
126. We acknowledge Mrs K is upset that medical staff did not explain what the injection would mean, but we do see she consented to it. As we have set out above, it was clear Mrs K was suffering from a PPH and needed immediate treatment.
127. Based on the information we have seen, we are satisfied medical staff acted in line with RCOG haemorrhage guidance.
128. We understand Mrs K is also upset that medical staff pulled out her placenta. We discussed this with our obstetrician adviser who told us that the midwife delivered Mrs K’s placenta by a technique known as controlled cord traction.
129. This essentially means the midwife pulled the placenta out by its cord. As we have set out above, prompt removal of the placenta was key to addressing Mrs K’s PPH and the way in which it was removed was in line with NMC guidance.
A doctor touched Mrs K and her baby without consent 130. Mrs K said minutes after giving birth a doctor entered the room and began touching her and her baby.
131. She acknowledges they were likely trying to reassure her but said there was no medical need for this physical contact. Her birth plan specifically mentioned clinicians should obtain consent before touching her.
132. The Trust said it reviewed Mrs K’s medical records and cannot find any information which relates to a doctor touching her without consent or that she had raised such concerns at the time.
133. The Trust adds that patients will need to be flexible and be prepared to do things differently from their birth plan if complications arise. It also acknowledges clinicians should read a patient’s birth plan, so they are aware of the patient’s wishes.
134. Section 46 and 47 of GMC guidance says doctors must be polite and considerate. It also says doctors must treat patients as individuals and respect their dignity and privacy.
135. Having considered both Mrs K’s and the Trust’s respective positions, we agree there is nothing we can see in the medical records which corroborates the events Mrs K describes. This being said, just because something is not recorded in the medical record does not mean it did not happen.
136. We are persuaded by Mrs K’s account that a doctor entered the room and began touching her and her baby. This is because her account is plausible and we understand a doctor may, for example, wish to check both mother and baby are well following birth and provide some reassurance. This could involve some physical contact.
137. The doctor who visited Mrs K should have been aware of the preferences set out in her birth plan and should have asked permission before touching her and her baby. Mrs K said she suffered a panic attack as a direct result of the doctor touching her.
138. We recognise Mrs K had just given birth and was likely feeling vulnerable. We therefore understand why it was important that medical staff asked permission before touching her.
139. We do not think the doctor’s actions are in line with GMC guidance.
140. We think the doctor failing to ask permission before touching Mrs K and her baby likely led to some avoidable upset and distress.
141. We think this emotional impact was primarily felt at the time and was not long lasting. We acknowledge Mrs K’s account it led to a panic attack. We consider this meets level two in our severity of injustice scale.
142. While the Trust says there is nothing in the records to describe this incident it acknowledges its actions upset Mrs K and caused avoidable distress alongside a panic attack. It also notes that her experience would be shared with staff to inform future practice.
143. Having carefully considered the Trust’s remedial action, we are satisfied its apology during the complaints process and its discussion with staff to share learning following the incident is proportionate to put right what went wrong.
144. The Trust says it shared learning during meeting ‘huddles’ but they are not documented. For this reason, it cannot supply us with any evidence of what it discussed.
145. We are satisfied they took place as the Trust appears to have actively attempted to share thinking in other elements of Mrs K’s complaint (the ‘complaints feedback and learning’ bulletin we previously discussed). We have no reason to doubt it shared this learning too.
146. We have decided to take no further action on this element of Mrs K’s complaint based on the remedial action the Trust has already undertaken. We hope we have clearly set out our rationale for our decision, and it provides Mrs K with some reassurance that we have carefully considered her concerns.
No mental health support 147. Mrs K said she told a midwife she was feeling unwell and felt she may be having a panic attack. She tells us she asked the midwife for mental health support but was told it was not available.
148. We appreciate Mrs K had just been through childbirth and was likely feeling vulnerable and both physically and mentally exhausted. We therefore understand this kind of support was important to Mrs K.
149. The Trust said it unfortunately did not have a 24-hour mental health midwife service. It explains that if a patient urgently requires mental health support, it can ask the obstetric team for review to see if it needs to make a referral to an on-call psychiatrist.
150. The Trust said it asked if Mrs K wanted to remain in hospital to receive further support and explained that if she left hospital any home support would be limited. It said Mrs K declined an inpatient stay and wanted to go home, so it was unable to offer her further specialist support.
151. GMC guidance sets out how doctors can provide good care. Section 15 says a doctor must refer a patient to another practitioner when this serves the patient’s needs.
152. The NMC guidance set out a paragraph 107 is also relevant here.
153. Our midwife adviser said this incident may not have necessitated an urgent referral to the mental health team. They also note the Trust are correct in stating that if urgent mental health support is needed, the obstetric team could make a referral to an on-call psychiatrist.
154. The medical records note Mrs K was feeling ‘light headed’ and this was likely ‘anxiety related’. She asked if there was any support available to her. The midwife explained they could offer support as an inpatient but not at home. The records state Mrs K ‘does not want to stay in hospital’.
155. Based on what we have seen, we are satisfied medical staff appropriately advised Mrs K she would need to remain in hospital if she felt she needed mental health support. She appears to have decided she did not wish to remain in hospital.
156. We are satisfied the Trust’s medical staff acted in line with both NMC guidance and GMC guidance in the support it offered Mrs K.
No bed following birth 157. Mrs K tells us that following birth she was not offered a bed and just had some ‘plastic cubes’ to rest on. She said when she asked the midwife for a bed, she was asked whether she wanted to remain in hospital. Mrs K said staff offered no comfort because she wanted to go home.
158. The Trust said its birthing centre rooms consist of pull-down double beds which should be available to mothers following birth. The Trust provided an apology and said it had shared her experience with the wider midwifery team to ensure beds are always offered to mothers.
159. The NMC guidance set out a paragraph 107 is also relevant here.
160. We appreciate Mrs K will have needed to rest after childbirth. The provision of a bed is an essential item of comfort which should have been readily available to her. We recognise the lack of a bed will likely have caused avoidable upset and distress.
161. We do not see the Trust’s actions here are in line with NMC guidance.
162. We think the emotional impact caused by the lack of a bed was primarily experienced at the time. We do recognise this upset and distress may have lasted for several months following the birth. We can therefore see Mrs K is at level two of our severity of injustice scale.
163. We do not think an apology and reassurance that staff have been reminded of good practice alone is sufficient and therefore see further remedy is appropriate to fully put right the impact of what went wrong.
164. The Trust has agreed to provide Mrs K with a financial remedy to help put this matter right. We will discuss this in more detail at the end of our statement.
No feeding support 165. Mrs K tells us she is concerned midwives gave no post birth feeding support while she was in hospital. She said her baby barely fed for several hours following birth because she was upset, had suffered a panic attack and felt unable to feed her baby.
166. We discussed Mrs K’s request for mental health support earlier in this statement. We recognise Mrs K was likely very distressed following the birth of her baby and this distress may have impacted upon her ability to feed her baby. This section will focus upon what midwives did in response.
167. The Trust said the medical records document that 15 minutes after birth, Mrs K’s baby was showing signs of being ready to feed and had attached to her breast for milk. It said the midwife offered to assist with the breastfeeding, but Mrs K declined this assistance.
168. It said 30 minutes after birth Mrs K’s baby ‘appeared to be rooting at the breast’ so the midwife offered further assistance, but this was also declined.
169. Section 2 of NMC guidance says nurses must work in partnership with people to deliver care effectively and respect the level to which people receiving care want to be involved in the decisions about their own health.
170. Sections 1.3 to 1.3.3 of NICE guidance says at each postnatal contact medical staff should ask parents if they have any concerns about the baby’s general wellbeing.
171. Sections 1.5.13 to 1.5.15 of NICE guidance set out that medical staff should assess breastfeeding and identify and address any concerns. This could mean adjusting the baby’s positioning and attachment to the breast, for example.
172. We can see Mrs K’s baby had ‘skin to skin’ contact immediately after birth in accordance with her birth plan. Skin to skin contact helps to calm the baby and stimulate their feeding instincts.
173. Mrs K is reported to have requested the baby to do a ‘baby crawl’ to the breast following birth and declined any assistance. Baby crawl or breast crawl is where the baby is allowed to use their rooting reflex to locate the nipple and their sucking reflex to start breast feeding.
174. At 3.30pm we can see a midwife documented Mrs K’s baby has ‘had a few licks and sucks’ and feeding support was again offered but Mrs K declined it.
175. We can also see the subsequent medical records document ‘has colostrum may give baby this as very tired. Encourage skin to skin hand expression’.
176. At 4.05pm we can see further documentation in the medical records that Mrs K’s baby was ‘rooting’ (looking to feed) when medical staff were carrying out an examination of the baby. Mrs K is reported to have again declined feeding assistance at this stage.
177. Later that same evening at 5.52pm Mrs K’s baby was noted to be ‘having a few more licks and sucks. Hand expressed into mouth and given approximately 2mls colostrum via syringe.’
178. Our midwife adviser said these extracts demonstrate Mrs K received active midwifery support for her breastfeeding while in hospital.
179. Based on the evidence we have seen, we are satisfied medical staff provided breastfeeding support to Mrs K in line with both NMC guidance and NICE guidance.
180. We have therefore decided to take no further action in this element of her complaint.
Discharge 181. Mrs K tells us she was discharged from hospital without support to get home despite her partner not driving and her being in slippers having just given birth.
182. Mrs K said they were desperate to leave so she got a taxi home while her partner and her baby waited in the reception area. She said she then drove back to the hospital to collect them.
183. The Trust said it does not currently provide hospital transport for mother’s returning home following birth. It said this approach is standard practice amongst other NHS Trusts.
184. The Trust explains its staff advised that they could not offer transport home at the time and encouraged Mrs K to contact a family member to come and collect them. It said its staff understood Mrs K had contacted a family member for support to get home.
185. The NHS’s information resource ‘How to organise transport to and from hospital’ which is freely available on the internet sets out that transport to and from hospital will depend upon whether it is an emergency.
186. Our nursing adviser said an ambulance took Mrs K from her home to the hospital as she was in labour and this was an emergency, so warranted transport. Following birth, however, there was no emergency and so hospital transport would not be offered as a result.
187. The NHS information resource sets out: ‘You'll normally be expected to make your own way to hospital if it's not an emergency. Hospital parking can be expensive and limited, and you may not be able to leave your car there overnight. So, you may want to ask a friend or relative to take you to hospital and collect you after you've been discharged.’
188. Our nursing adviser adds that it is the responsibility of every birthing couple to arrange their own transport. They note this is not unique to this NHS Trust and that it is a national expectation.
189. We recognise Mrs K and her partner had been through a stressful experience, and they were likely exhausted and just wanted to go home. It must have been very upsetting for Mrs K to have to go home, collect her car and return to the hospital after having given birth.
190. We think the Trust’s medical staff acted in line with our Principles which say public bodies should aim to ensure that customers are clear about their entitlements, about what they can and cannot expect from the public body, and about their own responsibilities.
Midwives visit 24 hours after birth 191. Mrs K tells us a midwife visited her home to give feeding support around 24 hours after she gave birth. She said the midwife asked if she could touch her to show how to hand express (stimulating the breast to produce milk) and without consent, grabbed her breast.
192. Mrs K said it was a horrible experience and felt the staff member needed to use their words for simple instruction, rather than being hands-on in the first instance.
193. The Trust provided apology and clarified this approach is not usual practice. It said it shared her concerns with its wider midwifery team for learning.
194. NMC guidance at section 1.1 says midwives should treat people with kindness, respect and compassion.
195. Our Principles say public bodies should acknowledge when mistakes happen. It says public bodies should explain what went wrong, provide apology and put things right quickly and effectively.
196. While the Trust said there is nothing in the medical records to indicate the midwife who visited Mrs K attempted hand expression it appears persuaded that this event happened as Mrs K described.
197. We are also persuaded by Mrs K’s accounting owing to the clear and direct nature of her description. Her allegation of a midwife engaging in hand expression is also something which midwives will commonly do, once they have obtained consent.
198. As such we view Mrs K’s account as accurate and do not see the midwife’s actions are in line with NMC guidance. We therefore see an indication of a failing.
199. We acknowledge Mrs K will likely have been upset by the midwife’s actions and that this upset will primarily have been experienced at the time. We do not see this upset is likely to have been long-lasting or something which would not fully resolve in the fullness of time.
200. We therefore consider Mrs K to be at the lower end of level two in our severity of injustice scale.
201. We can see the Trust provided an apology during the complaints process and it also supplied evidence to our Office that this incident was included in its ‘complaints feedback and learning’ bulletin (we previously discussed this at paragraphs 90 and 91).
202. The Trust said it shared this bulletin with the various medical teams to raise awareness of how medical staff should approach patients when offering feeding support.
203. We can see this bulletin emphasises the importance of using the correct language when asking a woman whether she would like help with feeding her baby and to always ask permission and gain consent before doing so.
204. Having carefully considered this element of the complaint we are satisfied the Trust’s remedial action during the complaints process is sufficient to put right the impact of what went wrong. We think its actions are in line with our Principles.
205. We have therefore decided to take no further action in Mrs K’s complaint.
Apology and Financial remedy 206. As set out at paragraphs 56 to 60, we think the Trust should provide an apology to Mrs K. The Trust agreed to write to Mrs K and apologise for the matters set out in this part of her complaint.
207. As set out at paragraphs 86 to 93 and 161 to 164, we think the Trust should provide some financial remedy to help fully put right what appears to have gone wrong in these parts of her complaint.
208. While we are pleased the Trust provided apology or some sort of service improvement during the complaints process, we see financial remedy is warranted here due to the level of emotional impact caused to Mrs K.
209. This specifically concerns Mrs K’s complaints relating to the handling of her colostrum and the lack of a bed following birth.
210. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we asked the Trust whether it would be willing to pay Mrs K £250.
211. The Trust confirmed it would be willing to pay Mrs K this sum of money. We are satisfied this financial sum alongside the remedial action it has already carried out is enough to put right the impact of what went wrong.
212. If Mrs K would like to accept this sum, she should let us know and we will ask the Trust to get in contact with her.