Report Date

31/01/2025

Case Against

Betsi Cadwaladr University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202403062

Outcome

Early resolution

Ms X complained that she had been unable to register the premature birth of her child, due to the doctor recording that there were no signs of life. This was at odds with her experience at the time of the birth. The matter was referred to the Coroner who made the decision that there were no signs of life at birth and therefore the birth could not be registered. This decision was made 2 weeks after the birth because of a delay in the doctor providing a statement to the Coroner.
The Health Board’s own investigation found that there were shortcomings in the documentation and communication on the day concerning signs of life. It apologised for this to Ms X and shared the learning from the events at a clinical forum. Ms X remained unhappy with the response and made a complaint to the Ombudsman.
The Ombudsman noted the delay of 2 weeks between the birth and the Coroner’s decision. This was due to a delay in the doctor concerned giving a statement to the Coroner. The delay caused additional distress to Ms X and her partner, because the period of uncertainty was longer than it should have been and they had been expecting to register the birth. The Ombudsman concluded that the Health Board should have been more proactive in contacting the doctor and ensuring that a timely statement was given. This was a shortcoming and the Health Board agreed to provide Ms X and her partner, within 3 weeks, with a written apology for this delay.