Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs Q complained about the actions of Betsi Cadwaladr University
Health Board that led her to suffer a massive obstetric haemorrhage (“MOH” – blood loss of more than 1500ml following delivery) during the delivery of her second child on 17 September 2018.

The Ombudsman’s investigation found that whilst there were no clear indications that Mrs Q would suffer a MOH upon delivery, it should have been realised sooner by staff that Mrs Q had significant blood loss and consultant input should have been earlier, which would have led to Mrs Q being transferred to theatre much sooner than she was – upwards of 45 minutes. This delay meant it was more likely than not Mrs Q spent longer in the intensive therapy unit, and intubated, than she should have
been. It also meant Mrs Q stayed longer in hospital than she should have done. This was a service failure and an injustice to Mrs Q, and the Ombudsman upheld the complaint.
The Ombudsman recommended that the Health Board apologise to Mrs Q and share the report with all maternity staff to highlight the issues raised about MOHs. The Health Board was also asked to confirm staff had undergone, or were undergoing, training in relation to the management of obstetric emergencies, including the management of MOHs. The Health Board agreed to implement the recommendations.