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Ms D complained that midwives at the University Hospital of Wales (UHW) wrongly informed her that her pregnancy dating scan revealed that she had suffered a ‘silent’ miscarriage. This error was detected only because Ms D elected to undergo uterine evacuation at a different hospital. There, a more thorough type of scan was performed which detected a healthy, viable foetus.

The Ombudsman upheld Ms D’s complaint and found that the Health Board had failed to implement guidelines issued by the Royal College of Obstetricians & Gynaecologists (RCOG) that were designed to prevent the misdiagnosis of early pregnancy loss. These guidelines require midwives to conduct a TV scan in all such cases. The Ombudsman also found that the initial dating scan had been incompetently conducted and that midwives failed to take account of Ms D’s relevant medical history. The Ombudsman recommended that:

(a) The Health Board provides Ms D with a written apology and, in recognition of the inconvenience and expense incurred in obtaining alternative antenatal care, makes a payment to Ms D in the sum of £1,500.

(b) Further to the Health Board agreeing to take immediate steps to implement RCOG guidance in respect of the diagnosis of early pregnancy loss and to promptly notify all relevant clinicians within the Directorate that it has done so, it provides documentary evidence of how this process was accomplished.

(c) The Health Board provides evidence that it has reviewed / assessed the competence of its midwife sonographers in respect of the diagnosis of silent miscarriage.

(d) The Health Board shares with the Ombudsman the outcome of its complaint investigation review of this case (its Root Cause Analysis).

A copy of the full report is available below.