Decision Report 202102766

Summary

C complained about the care and treatment they received by the board. C was pregnant and called triage as they thought their mucus plug (a protective collection of mucus in the cervical canal) had passed and that they noticed green discharge. C was advised to stay at home and call back if they had further concerns. C went to hospital later that day and underwent an emergency caesarean section to deliver their baby (A). A appeared well following birth, but soon deteriorated. A was initially diagnosed with hypoxic ischaemic encephalopathy (a type of brain damage), and then subsequently diagnosed with quadriplegic cerebral palsy (a lifelong condition that affect movement and co-ordination).

C complained to the board about the advice provided not to attend hospital during the initial call to triage, and about the care and treatment during delivery and immediately afterwards. C believed that clinicians delayed in taking appropriate action in response to A's symptoms and considered this may have impacted their health.

In response to the complaint, the board recognised that C's recollection of the call to triage differed from the notes taken but concluded on the basis of the information available, that the assessment and advice was appropriate. The board gave a detailed account of the care and treatment provided to C and A from C's attendance at hospital, through to delivery and in the period following A's birth. The board explained the decision to proceed to an emergency caesarean section and concluded that this was appropriate and timely. The board also concluded that it was impossible to say if the outcome for A would have been different had C attended hospital earlier, and it was unlikely an earlier birth from the time of admission would have altered the outcomes. C was dissatisfied with the board's response and brought their complaints to our office.

We took independent advice from an obstetrician (specialist in pregnancy and childbirth) and from a consultant neonatologist (specialist in the medical care of newborn infants, especially ill or premature newborns). We found that the call to triage and advice given not to attend hospital was reasonable. With respect to the care and treatment during and following delivery of A, we found that whilst there was some information missing regarding the monitoring of A's heart rate, the decision making regarding the timing of proceeding to a caesarean section and the care immediately following birth was reasonable. A was given appropriate care when their health deteriorated following birth and there was no unreasonable delay in admitting them to neonatal intensive care. Therefore, we did not uphold C's complaints.