Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Cwm Taf Morgannwg University Health Board
Ms A complained about care she received from the Health Board whilst giving birth to her baby. This included: the complainant’s access to food and drink and midwifery presence during labour; post-natal midwifery care; the length of time Ms A waited for Obstetrician review and the management of episiotomy and forceps delivery consent processes.
The investigation found the majority of Ms A’s care was appropriate, including midwifery presence during labour; post-natal midwifery care; how long Ms A waited for Obstetrician examination and the consent processes for the episiotomy and forceps delivery. These aspects of the complaint were not upheld. However, the Health Board should have informed and encouraged Ms A in relation to the consumption of food and drink during labour, in-line with national guidance and standards. The Health Board should also have both provided information to, and involved Ms A in, decisions about the plan of care during the second stage of her active labour. These elements of the complaint were upheld. The investigation identified that these were failures in care which caused Ms A injustice. Specifically, exhaustion arising from a lack of energy during labour; worry and uncertainty about the progression of her labour because of this; and disempowerment, worry and uncertainty because she was not fully informed and involved in her plan of care during the second stage of labour.
The Ombudsman recommended that the Health Board should provide Ms A with a written apology for the failures identified; should also remind relevant staff of the importance of relevant standards and guidance; and conduct a sample audit of records in the service area to identify and address any shortcomings in relation to practice associated with the failures identified. The Health Board accepted the recommendations.