Decision Report 202404774

Summary

C gave birth involving a forceps delivery (where a medical instrument is used to assist birth) and suffered a fourth-degree perineal tear (significant injury to the area between the vaginal opening and anus). C had surgery to repair the perineal tear and again to have treatment for retained placenta (where some placenta remains in the womb after birth). C complained about the maternity care and treatment in hospital, the board’s communication with C in hospital and the board’s handling of C’s complaint.

The board apologised for poor communication during the birth and said that they were carrying out actions to improve management of obstetric and anal sphincter injury and obtaining consent for instrumental birth.

We took independent advice from a consultant obstetrician. We found that the maternity care and treatment provided to C during the time of the birth was reasonable. We did not uphold this aspect of the complaint.

We found that the board’s communication with C when C was in hospital was unreasonable. Though the birth situation was urgent, it was not an emergency, and a fuller discussion should have taken place with C regarding the forceps delivery. We upheld this aspect of C’s complaint.

We found the actions that the board said they were carrying out were reasonable in response to the failing in communication.

We found the board’s complaints handling was unreasonable, because C’s initial complaint was not reasonably progressed, the scope of the complaint investigation was not agreed with C, the board’s response to the complaint was not reasonably clear, and there were regular and significant delays in the board’s communication with C regarding the complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• All staff should be aware of how to identify and progress complaints about the board. The board should provide full, clear and timely complaint responses in line with the NHS Scotland Complaints Handling Procedure.

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.