Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mrs N complained about aspects of her care during her pregnancy and delivery of her baby, specifically:

•Failure to prescribe iron tablets earlier in her pregnancy.

•Monitoring of her and her baby during the final days of her pregnancy.

•Surgery carried out following her caesarean section at the hospital, resulting in her being transferred to another hospital and the removal of a kidney.

Very sadly, Mrs N’s baby did not survive, Mrs N suffered heavy bleeding from the artery supplying blood to the kidneys and had to have a kidney removed.

The Ombudsman found that the iron supplement Mrs N was taking at 26 weeks of pregnancy, together with the dietary advice she was given, was appropriate to address her borderline low haemoglobin level. The actions of the community midwife and doctor in the week before Mrs N’s baby was born were appropriate, and further monitoring would not have altered the outcome. Mrs N’s transfer to the second hospital and subsequent surgery there, were appropriate and timely, and the removal of Mrs N’s kidney was the only option to save her life. The Ombudsman did not uphold the complaint.