Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the Health Board’s (“the Health Board”) management of her labour in March 2020 after a scan found that that her baby was large for the due date. Mrs A said the Health Board failed to counsel her properly about options for the birth, to listen to her and provide respectful, empathetic care and effective pain relief, and to undertake an earlier caesarean section (“CS”) when it was indicated.

The Ombudsman found that there were no clinical indications for an earlier CS. There was however, insufficient evidence that Mrs A was counselled appropriately about the risks and benefits associated with a vaginal birth and alternative options for care with a suspected large-for-dates baby. Mrs A experienced significant difficulties during her labour that might have been avoided with an earlier elective CS and the lack of appropriate counselling caused uncertainty about her ability to make informed choices about her care.

The Ombudsman was unable to reconcile Mrs A’s experience of excruciating pain during her labour with the evidence of the Health Board’s records providing a consistent account of well managed pain from all the clinicians involved in her care. However, there was evidence of occasions when Mrs A had expressed pain when in established labour and additional support with gas and air was not provided when it could have been. Consequently, Mrs A’s labour was more painful than it needed to be.

The Ombudsman recommended to the Health Board that it should apologise to Mrs A for the failings identified, share the findings with its obstetricians and midwives for organisational learning, and take steps to ensure that all expectant mothers with a suspected large-for-dates baby are counselled appropriately about their birth choices.