Miss C complained to Cwm Taf Morgannwg University Health Board (“the Health Board”) about her management and care in relation to her pregnancy loss on 2 August 2023 and queried whether it was clinically appropriate.
The Ombudsman’s investigation found that there were instances when nursing care fell below an acceptable standard. The Ombudsman was concerned that given Miss C’s blood loss and dizziness, as noted in the retrospective nursing entry, her vital observations were not taken, as these would have highlighted her clinical deterioration and would have alerted the clinicians to the gravity of her condition. The investigation found that Miss C’s care should have escalated sooner and that there were missed opportunities to do so. The Ombudsman concluded that the service failings in this case were fundamental, and to that extent, unacceptable and resulted in significant blood loss and a frightening near-death experience for Miss C and her partner causing them significant injustice.
The investigation found that the shortcomings in nursing care were compounded by inadequate record keeping, which meant that clinicians undertaking Miss C’s care in the intervening period lacked information about the seriousness of her condition. The Ombudsman was concerned that the Health Board’s investigation did not identify failings in the care and management Miss C received on 2 August, including the shortcomings in nursing care and record keeping. Given these administrative shortcomings and service failings, Miss C’s complaint was upheld. In terms of complaint handling, the Ombudsman found that the Health Board did not identify failings in Miss C’s care and management (on 2 August) and this reflected a lack of diligence and rigour in the investigation process. It also meant opportunities were missed to properly learn lessons and put things right quickly and effectively.
The Ombudsman made a number of recommendations which included the Health Board apologising to Miss C for clinical failings identified by the investigation, paying her a sum of £750 for distress caused to her as a result of poor nursing care and £250 for poor complaint handling. As part of wider learning the Health Board agreed to share the report with staff involved in Miss C’s care.