CSummary
Ms C was assessed as low risk during her pregnancy and it was, therefore, considered suitable for her to deliver her baby at the Community Midwifery Unit at Vale of Leven District General Hospital. After going into labour she was admitted to the maternity unit but her labour was slow to progress. Several hours after admission, an examination found that her baby was in a posterior position (when the back of the baby's skull is in the back of the mother's pelvis). This meant that the delivery would be more complicated and would be likely to need a higher level of care than was available at the maternity unit. Staff called an ambulance to transfer Ms C to the Royal Alexandria Hospital. The ambulance service was particularly busy so the transfer took longer than expected. There was also a delay in the ambulance team accessing the building as they did not know the maternity unit. Ms C was given an episiotomy (a minor surgical cut that widens the opening of the vagina during childbirth) very shortly before she was transferred. Her baby was unwell at birth and she was transferred to another hospital for specialist neo-natal treatment.
Mr and Ms C complained to the board that the maternity unit did not reasonably explain in advance the transfer arrangements to hospital from the unit in case of an emergency; did not provide a reasonable standard of maternity care; delayed making the decision to transfer Ms C to hospital; contributed to delays during the transfer process; and that the board did not handle their complaint in line with the complaints procedure.
The board conducted a Significant Incident Review following the complaint, identifying a number of failings in Ms C's care, and recommending improvements at the maternity unit.
I took independent midwifery advice on this complaint. Regarding the information received about an emergency transfer to hospital from the maternity unit, it was clear that Ms C's understanding of the transport arrangements was not correct. She had also not been given any written information. The board acknowledged that Ms C should have been given clearer information, and they had amended a leaflet to include the transfer information. However, my adviser noted that the leaflet should be provided to women before they have chosen where to give birth.
We found several failures in the maternity care provided to Ms C in the maternity unit. This included a failure to properly assess her on admission or identify a clear plan of care; lack of monitoring throughout her labour; poor documentation, particularly of care planning and regarding handovers between staff; and also the episiotomy was undertaken inappropriately and possibly unnecessarily. The poor standard of care put Ms C and her baby at unnecessary risk.
As a result of some of the failures above, the decision to transfer Ms C to hospital was delayed. If her labour had been managed properly, she could have been transferred before it was an emergency. I am critical that the board's SIR did not highlight this delay and that they have yet to apologise for it.
The delay in the ambulance arriving at the maternity unit was due to pressures on the ambulance service and therefore out of the board's hands. However, the difficulties the crew experienced getting into the building were avoidable, and I am critical of the lack of action from the maternity unit staff.
The board clearly did not deal with Mr and Ms C's complaints within the timescales of their guidance (Guidance to Staff in Dealing with Complaints). Additionally, the board's final response to their complaints was in the form of notes from meetings, rather than a formal letter clearly stating whether complaints were upheld and providing a meaningful apology.
I upheld all of the complaints.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that the leaflet entitled 'Having your baby at the Vale of Leven CMU' is given to women before they have made a decision about where they would like to give birth, and revise the wording of the leaflet as appropriate; 30 November 2015
- (ii) consider the need to review the NHS Greater Glasgow and Clyde Obstetric Guidelines, in line with National Institute for Health and Care Excellence Guidelines on Intrapartum Care (2014); 30 November 2015
- (iii) reflect on the findings of this case, and consider whether the provision of aromatherapy at the Unit should be offered on a 24 hour basis; 30 November 2015
- (iv) extend the use of the new tool for handover of care, so that it is applied to telephone handovers when transferring care from the Unit to Royal Alexandria Hospital; 30 November 2015
- (v) consider implementing a system for staff rotations from the unit to Royal Alexandria Hospital on an annual basis, if this is not already in place; and 7 January 2016
- (vi) apologise to Ms and Mr C for the failings identified in this report, and the distress this caused them and Baby C. 30 October 2015