July 2022
23. Miss R complains the Trust failed to follow its plan to remove her miscarried pregnancy. She says the changes in plan meant she had to go back and forth to hospital during an awful time. She says the Trust did not admit her when it said it would, which led to her miscarrying the pregnancy while at home. We know this was very traumatic for her.
24. The Trust has apologised for Miss R’s experience after she miscarried her pregnancy.
25. The Trust’s care pathway for medical management of miscarriage contains a series of tick boxes for conditions that need to be met and actions to be completed before a patient can be managed at home. One of these tick boxes is used to confirm the crown rump length (CRL - the measurement of a foetus from the top of the head to the bottom of the buttocks) is under 30mm.
26. The Trust initially offered Miss R the choice of medical management at home, which she agreed. It provided her with the medication to take home. We can see from her form the Trust had ticked to confirm the CRL was under 30mm. However, the Trust did so in error as the records tell us the CRL was 44mm.
27. This explains why the Trust later asked Miss R to return the medication back to hospital and agreed to give her medical management as an inpatient instead. The Trust therefore failed to act in line with its pathway.
28. The NICE guidance for medical management of miscarriage says to offer mifepristone, and 48 hours later follow up with misoprostol.
29. After Miss R took the first medication, the Trust told her on two occasions on consecutive days to go to back to hospital. The plan was for her to return two days later for the second medication as an inpatient.
30. The records from when Miss R arrived for this appointment say, ‘[gynaecology] team on call today were not aware/ handed over to expect this patient’. This indicates the Trust had not communicated about, or planned for her return properly. The notes show the team were unable to accommodate Miss R that day and told her to go home and return to hospital the following day.
31. Given Miss R had taken mifepristone two days earlier, the Trust asking her to return for misoprostol the next day is not in line with the timeframe outlined in the NICE guidance.
32. Our adviser explained while mifepristone alone is not used to remove the pregnancy, it does make it more likely to happen on its own. This tells us it was important for the Trust to adhere to the 48-hour timeframe.
33. Miss R had a miscarriage later that day, after she had returned home. We know this was very distressing for her.
34. In summary, the Trust did not initially correctly follow its pathway on medical management of miscarriage. It then failed to appropriately plan for her return, leading to its failure to act in line with NICE guidance.
35. We have carefully considered the impact of the failings.
36. Our adviser explained cases where miscarriage is discovered unexpectedly during a scan are often particularly distressing for women. This provides some context into how difficult this period would have been for Miss R. We therefore acknowledge the significant distress Miss R experienced would have been primarily caused by the delayed miscarriage itself, rather than the failings.
37. We can see that Miss R sought therapy from the NHS while pregnant in 2023. The discharge letter confirms Miss R’s experience after the delayed miscarriage in 2022 was affecting her mood, indicating this was a key factor in her seeking help. Miss R told us both delayed miscarriage itself and the care the Trust provided caused her a lot of distress and led to her seeking help while she was pregnant.
38. We consider the Trust’s actions contributed to this distress at what was already a very difficult time.
39. We found the Trust gave Miss R wrong information about being able to have her medical miscarriage at home. We can see it did rectify this error within one day. As Miss R had not taken the medication at home we have not seen a direct impact on her treatment. While she had to return the medication to the Trust, she needed to return to the Trust to have medical management as an inpatient.
40. We do acknowledge the uncertainty around the plan for her care would have caused Miss R some additional concern.
41. We found the Trust failed to adequately plan for her return to hospital to take the second medication. The notes tell us the Trust could not admit her because there were no side rooms, and it did not have enough staff to take her onto the ward.
42. Given the Trust knew it needed to admit her 48 hours in advance, our view is it would have been able to accommodate her had it arranged the admission in line with its plan.
43. Had this happened, Miss R would have been in hospital when she passed the pregnancy, rather than at home.
44. The Trust’s pathway does not permit medical management at home when the CRL is above 30mm. Our adviser explained this is likely in place because there is usually heavier bleeding when the foetus is larger. Therefore, the Trust’s pathway acknowledges patients with a pregnancy above 30mm (such as Miss R) would have a worse outcome at home rather than in hospital.
45. The records show at around 5pm Miss R called the Trust to report severe pain. Around five minutes later her partner called back to say she was ‘bleeding out’ and the Trust told them to ring emergency services. We can see how this sudden bleeding at home was likely more distressing than if the medical management had happened in hospital, where she would also have had medical professionals to support her.
46. An ambulance attended to Miss R and took her to hospital around an hour later. We can see the Trust’s gynaecology team reviewed her at around 11pm and she was sent home that night.
47. Miss R explained how difficult this period was as she was waiting around in the ED, covered in blood after a really distressing experience. Passing the pregnancy would have been very distressing for Miss R even if she was admitted to hospital. It is more likely she would have had her own designated bed and would likely not have had to wait a significant amount of time without being cleaned up.
48. Our view is the miscarriage itself would have been the main cause of Miss R’s distress. We consider her passing the pregnancy at home, not in line with the Trust’s plan, added to this distress. Particularly as she then had to make her way to hospital and wait in the ED.
49. We know this experience had lasting impact on Miss R given she accessed support for it during her next pregnancy.
November 2023
50. We then turn to Miss R’s complaint about the care she received when she gave birth in 2023. Miss R complained of significant abdominal pain and other symptoms for several days after her c-section. She says the Trust’s staff told her it was normal to have these symptoms after surgery.
51. Miss R is unhappy it took three days for the Trust to scan her and diagnose she had PI. She said she could have suffered a perforation (hole) in her bowel if the Trust did not intervene.
52. The Trust has apologised to Miss R for the delay in diagnosing PI and for her not feeling listened to. It said it provided feedback to staff involved in her care.
53. Our adviser explained PI can occur after any abdominal surgery and usually presents one to three days post-surgery. They explained as the bowel stops working gas builds up in the abdomen and food in the stomach cannot move on into the bowel to be fully digested. Therefore, the symptoms of PI include abdominal pain and vomiting as undigested food is brought back up.
54. The records show Miss R told Trust staff she was in pain throughout her admission after giving birth. The Trust gave her morphine (a strong opioid pain medication) regularly, particularly throughout the night after giving birth.
55. Miss R also informed the Trust of other symptoms. For example, Miss R said she had not passed wind or opened her bowels two days after the birth.
56. Our adviser explained that while these symptoms are associated with PI, they are common in a lot of patients who have had abdominal surgery. They added PI is not very common after a c-section and symptoms can take up to three days to present fully. Considering this, we can understand why staff considered Miss R’s symptoms were part of her recovery from her surgery in the first instance.
57. A clinician reviewed Miss R in the morning of 2 December and noted she had ‘10/10’ pain since surgery with tenderness in her abdomen. They noted she had still not opened her bowels and had vomited up ‘lots of old food’ the previous night. Given we know PI stops food moving into the bowel and is often vomited up, this seems like an important symptom. We cannot see the clinician arranged any follow up investigation to consider this new symptom further.
58. Our adviser told us the vomiting, along with the other symptoms having persisted for several days, would be a stronger indicator PI could be present. They gave their view that at this point, the clinician should have ideally suspected potential PI and arranged for further investigation.
59. Later that evening, a clinician who reviewed Miss R noted similar symptoms to the morning but arranged for a CTAP to investigate. This ultimately led to the diagnosis of PI. Miss R’s symptoms during this second examination were very similar to the first, albeit they had now persisted for around 12 hours longer. This gives weight to the idea that the Trust could have considered a potential diagnosis of PI in the morning.
60. Paragraph 15 of GMC guidance says clinicians must adequately consider their patient’s history and symptoms and arrange for appropriate investigations. Having weighed up the evidence including our adviser’s opinion, our view is the Trust did not act in line with GMC guidance in the morning examination.
61. Fortunately, the next day Miss R opened her bowels, indicating the PI had started to resolve.
62. Our adviser explained PI almost always resolves by itself as the bowel starts to work again after a few days. They explained the normal treatment for PI is to provide the patient with relief from the uncomfortable symptoms while waiting for the PI to resolve naturally.
63. After it suspected PI in the evening, the Trust drained Miss R’s stomach and stopped her from eating anything to prevent any further vomiting. Our adviser explained this was the correct approach.
64. We found the Trust could have put measures in place to make Miss R more comfortable around 12 hours earlier than it did. Our adviser told us that while this would have provided some relief to Miss R, it is unlikely to have been able to completely relieve her symptoms.
65. We understand Miss R’s concern that she could have perforated her bowel and been left with life-long problems. Our adviser explained perforation is a risk that presents in cases where there is a blockage in the bowel. They explained this is different from PI where the bowel stops working without a physical obstruction. Our adviser confirmed there was unlikely to be any long-term clinical impact on Miss R.
66. Our view is the Trust could have made Miss R more comfortable around 12 hours earlier than it did. We acknowledge she would have very likely still been in some discomfort during this period. We do not wish to diminish how awful she found this experience, as we know she had also just had a very difficult birth.
67. Level 1 on our Severity of injustice scale, includes one-off instances of service failures where the effect on the person is short in duration. It includes distress caused of up to two weeks or minor pain of no more than two days. As the Trust’s actions resulted in 12 hours of increased discomfort, this falls within this level.
68. For such cases we would generally consider an apology to be an appropriate remedy. We can see the Trust has already apologised to Miss R and agreed to feed back to staff as a learning point. We therefore consider the Trust has already taken appropriate action and we are not recommending anything further.