Decision Report 201801326

Summary

Mr and Mrs C complained about the treatment Mrs C received both during and after her pregnancy. Mrs C felt unwell throughout her pregnancy with nausea, heartburn and abdominal pain. Mr and Mrs C reported her symptoms during phone calls to the midwife unit. Mrs C was advised to take pain relief and get back in touch if the pain worsened. When Mr and Mrs C attended the Victoria Hospital for their 20 week scan they were told there was no foetal heartbeat.

After delivery of the baby Mrs C had bloods taken, and tests from the placenta, but waited more than ten weeks to see a doctor to discuss the test results. After chasing up the results Mr and Mrs C were told that bloods had been lost, requiring Mrs C to return to the ante-natal clinic for further testing. She was subsequently told she tested positive for lupus (an autoimmune condition that affects the body's defences against illnesses and infections) and required further blood testing. Errors in the testing meant that Mrs C had to return to the clinic again. Each time she had to wait with pregnant couples and found this distressing. Mr and Mrs C felt the miscarriage could have been avoided if Mrs C had received better treatment. They complained that Mrs C's lupus should have been diagnosed sooner, and that the loss of their baby might have been avoided.

We took independent advice from a midwife and a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the advice given to Mrs C each time she contacted midwives regarding her symptoms was reasonable. We did note, however, that Mr and Mrs C's account of the reported symptoms was not reflected in the records and we were unable to reconcile the two. We found that testing for lupus during pregnancy is unreliable because results may be falsely positive and that there were no clinical indicators for Mrs C to be screened prior to her miscarriage. We considered that the treatment Mrs C received during her pregnancy was reasonable and did not uphold this aspect of the complaint.

In relation to treatment after the miscarriage, we found that errors in the blood sampling were unreasonable. We noted that Mrs C had experienced a traumatic loss and that having to return to the ante-natal clinic several times to have bloods taken added significant stress to her situation. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for these failings in their care, with an acknowledgement of the impact this had on them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should consider whether alternative arrangements could be offered for future patients who have experienced stillbirth or miscarriage, particularly if the procedure could be carried out elsewhere.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.