Overview
The complainant (Mr C) raised a number of concerns with Grampian NHS Board (the Board) that the care given to his wife (Mrs C) and baby daughter (Baby C) at Aberdeen Maternity Hospital (the Hospital) was inadequate. Mrs C was admitted to the Hospital two weeks prior to Baby C's birth by caesarean section. Baby C died shortly after birth, having been born premature and very underweight. Mr C was particularly concerned about the refusal of medical staff to continue resuscitation on Baby C. It is of concern to me that a number of relevant and important clinical documents, including reference to the fact a post-mortem examination had been conducted, were not provided to my office by the Board until they were asked to highlight any factual errors in a draft version of this report. At this stage of our investigative process, the Board had already been asked, on two occasions, to provide all the relevant information they held. In addition, we had already obtained clinical advice, with my advisers providing comment on the clinical records and information as received. I am disappointed by the Board's decision not to provide such relevant information until this final fact checking stage. I expect all bodies to ensure that their responses to my office's enquiries are thorough and include all information which is of relevance to the complaints under investigation. The Board's omissions in this case undoubtedly hampered our investigations, caused increased stress and distress for the family involved, and are totally unacceptable, as well as unprofessional.
Specific complaints and conclusions
The complaints which have been investigated are that the Board:
- (a) failed to adequately manage the later stages of Mrs Cs pregnancy including the birth of her baby (upheld);
- (b) failed to adequately assess the possible success of continued resuscitation (not upheld); and
- (c) failed to adequately communicate with Mr and Mrs C (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) consider introducing guidelines for the management of small for gestational age foetuses, with reference to the Royal College of Obstetricians and Gynaecologists guidance of March 2013;
- (ii) undertake an assessment to ensure that the Obstetric Team has the correct training and equipment to perform assessments of extremely pre-term infants with abnormal umbilical blood flows, and prepare an action plan to address any shortcomings;
- (iii) provide evidence to demonstrate that following the death of a baby, full clinical examinations and investigations, including a post-mortem, are discussed with and offered to parents;
- (iv) demonstrate that the Board's guidelines about intrauterine death , which contain survival figures for babies of extreme prematurity, are referred to as appropriate by maternity and neonatal staff when discussing care with prospective parents;
- (v) remind all of the staff involved in Mrs C's care of the importance of obtaining signed consent forms for caesarean sections;
- (vi) issue a full apology to Mr and Mrs C for all of the failings identified in this report;
- (vii) draw this report to the attention of all neonatal, obstetric and maternity staff at the Hospital; and
- (viii) conduct a significant event analysis of Mrs C and Baby C's care from the point of Mrs C's admission until Baby C's delivery and treatment.