Mrs A (anonymised) complained about the care and treatment that she and her late son, Baby C, received from Glangwili and Withybush General Hospitals in West Wales in May 2016.

Mrs A complained that:

•There had been failures to monitor Baby C’s development during her pregnancy and labour and to provide her with a birthing plan

•There had been a failure to respond to her concerns about unusual pains during labour

•Following Baby C’s birth, there had been a failure to conduct necessary tests

•There had been a delay in Baby C seeing a paediatrician and receiving treatment

•There was a failure to conduct a full investigation into the cause of Baby C’s death which resulted in Mr and Mrs A being given different reasons for Baby C’s death.

•The Health Board failed to adequately respond to her complaint about the different explanations she was given

•Baby C’s death was incorrectly registered as a “stillbirth”


The Ombudsman upheld the complaint. He found that concerns raised by Mrs A during the pregnancy and in labour were dismissed by medical staff. During labour, there was no investigation of unusual sharp pains complained about by Mrs A, and there were delays in a consultant paediatrician attending when Baby C was born because he was given incorrect information on the location of the birth.

The Health Board failed to undertake appropriate tests on Mrs A and on Baby C after his birth. This affected the Health Board’s investigation into the cause of Baby C’s death and caused significant worry and distress to the family.

Furthermore, the Ombudsman found that Baby C’s death was incorrectly registered as a stillbirth rather than a neonatal death, meaning the parents were denied the opportunity to discuss organ donation. The Ombudsman concluded that there was an injustice for Mr and Mrs A as they will never know if their son would have survived if there had been no delays in treatment and in the consultant paediatrician attending after Baby C’s birth.

Commenting on the report, Public Services Ombudsman for Wales, Nick Bennett, said:

“Clearly Mr and Mrs A have been through a heart-breaking experience and I hope the outcome of my office’s investigation brings them some small comfort.

“There was a lack of ownership and consistency in Mrs A’s and Baby C’s care, and a whole host of failings that should not have occurred.

“The injustice arising from the decision to record a stillbirth has been significant for Mr and Mrs A as they believed that when Baby C had been passed to them he was alive and had died in their arms.

“It is vital the Hywel Dda University Health Board learns the lessons from these mistakes to ensure they do not happen again.”

The Health Board agreed to implement all of the Ombudsman’s recommendations including providing Mr and Mrs A with an apology for the failings identified, pay Mrs A £4,500 in recognition of the distress, delay and uncertainty she experienced in this matter. The Board also agreed to change Baby C’s status from “still born” to “neonatal death.”