Decision report 201204767

Summary

Mrs C's daughter (Miss A) was pregnant, and was admitted to hospital for her baby to be induced. However, her baby was born by emergency caesarian section (an emergency operation) the next day, and Miss A was discharged home a few days after that. On the day she was discharged, she had been reviewed and an ileus (a condition where the bowel stops contracting and relaxing to move the bowel contents) was suspected. However, Miss A was reviewed again later in the day, noted to be well and was discharged. She had to be readmitted to hospital the next day, with vomiting and a suspected bowel blockage. She needed surgery to release a suture which had been around part of her bowel, and the bowel was then re-sectioned (part of it removed).

Mrs C complained on Miss A's behalf that her daughter had not received a reasonable standard of medical care, and that she was released from hospital too early. She alleged that insufficient care had been taken when Miss A's caesarian section was carried out and that her bowel had been perforated because of this. However, the board said that Miss A's emergency section had been carried out in a routine manner and that she had suffered an unusual complication. Overall, they said that her care had been appropriate.

To investigate the complaint, we took independent advice from one of our medical advisers. Our adviser confirmed that Miss A's bowel injury was a rare but recognised complication of a caesarian section, particularly one that was not planned and was carried out in the later stages of labour, and that the records showed that all reasonable care had been taken during the operation. She also said that there had been no reason not to discharge Miss A, although some of the record-keeping could have been better.

Recommendations

We recommended that the board:

• remind all staff of the importance of timing and dating all entries in the record. Also that staff are reminded that when a complication is suspected, the subsequent records are explicit about the progress of the symptoms giving cause for concern.