Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs F complained about the care and treatment she received during her pregnancy and labour in November 2020. She specifically complained that she was not provided with appropriate information about her birthing options, taking into consideration her vaginismus condition (which caused involuntary tightening of the vaginal muscles) and was therefore unable to make an informed choice. She also complained that her birthing plan was not adhered to as she did not have an epidural when her cervix was 2cm dilated, she was not supported to breastfeed her son following his birth, and she was discharged from hospital without appropriate examination or being given appropriate information about after care of her episiotomy (a procedure to perform a cut to make the opening of the vagina wider) and anaemia (a condition caused by a lack of red blood cells).

The investigation found that Mrs F was not provided with sufficient information about the risks of birthing options for someone with vaginismus. It found that the Anaesthetic Team should have been contacted earlier to request an epidural for Mrs F and she therefore did not receive adequate and timely pain relief. There was no evidence that Mrs F received appropriate support to breastfeed her son. While it was found that Mrs F received appropriate treatment for her anaemia, and a lack of information regarding this did not cause her any harm, it was also found that Mrs F did not receive sufficient examinations and advice for her episiotomy wound which contributed to increased distress when she was experiencing pain. These complaints were upheld.

The Health Board agreed to the Ombudsman’s recommendations to apologise to Mrs F and make a financial redress payment of £1500 for the injustice caused from the failings identified. It also agreed to share the report with relevant clinicians, remind them of the importance of clear and contemporaneous records and remind clinicians that for patients with vaginismus this needs to be considered in regard to each birthing option to support the individual to make an informed choice. It agreed to remind midwives of relevant learning points including the importance of ensuring women in labour can access adequate and timely pain relief, visually inspecting the perineum after labour, and providing information to patients about what to do if they have concerns about the healing of their wound following discharge. It also agreed to provide the Ombudsman with a copy of the patient information leaflet regarding vaginismus and how it is managed in pregnancy, during birth and post-delivery.