Mrs A complained about the care and treatment that she and her late son, Baby C, received from the Health Board. Specifically, Mrs A complained that there had been a failure to monitor Baby C’s development during her pregnancy and labour, a failure to provide her with a birthing plan and a failure to respond to her concerns about unusual pains during labour. Mrs X also complained that there had been a delay in Baby C seeing a paediatrician, receiving treatment and a failure to conduct necessary tests after birth. Mrs A complained that the Health Board had not only failed to adequately respond to her complaint, but it had failed to conduct a full investigation into the cause of Baby C’s death which resulted in her being given different reasons for Baby C’s death. Finally, Mrs A complained that Baby C’s death was incorrectly registered as a “stillbirth”.

The complaint was upheld and it was recommended that the Health Board:

(a) Provides Mr and Mrs A with a meaningful apology for the failings identified in this report

(b) Pays Mrs A the sum of £4500 in recognition of the distress, delay and uncertainty she experienced in this matter, the cost incurred for the private scan and the time and trouble in bringing her complaint to this office.

(c) Identifies the clinicians and midwives responsible for the care of Mrs A and Baby C and discusses the content of this report in their supervision sessions, sharing any lessons learned with colleagues within the department

(d) Ensures compliance with the process for providing information to parents of babies that have been stillborn or neonatal death

(e) Changes Baby C’s status from “stillborn” to “neonatal death”.