Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Aneurin Bevan University Health Board
Ms B and Mr C complained that Aneurin Bevan University Health Board (“the Health Board”)failed to provide appropriate care and treatment during Ms B’s pregnancy and labour which resulted in the loss of their son, E. In particular, Ms B and Mr C complained that the Health Board failed to communicate with them about birth choices, failed to appropriately identify that E was presenting breech and failed to provide appropriate care and treatment during Ms B’s labour.
The Ombudsman’s investigation found that there was no documented evidence of any discussion with Ms B around the benefits and risks of delivery in each birth setting. This was a service failure. The Ombudsman found that the resultant uncertainty and distress was a significant injustice to Ms Band Mr C and accordingly, he upheld this element of their complaint.
The investigation also found that although Ms B’s antenatal appointments were in line with national recommendations, at the 36 week appointment there was no documentation of E’s presentation which was a service failure. However, at a midwife appointment 2 weeks later, the midwife documented that E was presenting head-first and E was also noted to be head first at the time Ms B first attended hospital during her labour. Asa result, this element of Ms B and Mr C’s complaint was not upheld. That said, the Ombudsman invited the Health Board to remind its midwives that foetal presentation should be assessed and documented.
Finally, the Ombudsman’s investigation found that on Ms B’s first attendance to the hospital during her labour, an appropriate assessment was undertaken by the midwife and it was appropriate to discharge Ms B home at that time. However, Ms B received a total of 38 minutes of care when she first attended the hospital, which was less than the recommended1 hour. The Ombudsman found however, that if Ms B had remained in the hospital for the recommended further20 minutes, it is unlikely that the breech position of E would have been suspected and diagnosed. The Ombudsman suggested that the Health Board review the Adviser’s comments in this regard.
The Ombudsman also found that on Ms B’s return to hospital, once the breech presentation of E and the cord prolapse was identified, appropriate action and management was undertaken. There was evidence of good communication and appropriate escalation. The midwives’ management of the cord prolapse was appropriate and in line with the national recommendations. As a result, this element of Ms B and Mr C’s complaint was not upheld.
The Ombudsman recommended that the Health Board should apologise in writing to Ms B and Mr C for the failings and share the report with relevant clinical staff for critical reflection. He also recommended that the Health Board should review the process of providing pregnant women with a birthplace decisions leaflet. Finally, the Ombudsman recommended that the Health Board should remind its midwives in the importance of documenting discussions with pregnant women about birth place choices.