Decision Report 202309086

Summary

C complained about the obstetrics (specialists in pregnancy and childbirth) care and treatment that they received from the board during and after the delivery of their baby by planned caesarean section. C said that there was a delay in diagnosing retained products of conception (tissue that remains in the uterus after a pregnancy) which led to infection. C also said that they were kept nil by mouth (not allowed to consume food or drink by mouth) for over 30 hours as their surgery for evacuation of the retained products kept being delayed.

We took independent advice from a consultant obstetrician and gynaecologist. We found that some aspects of C’s care and treatment were reasonable. However, a doctor should have attended when C passed a large clot. There was also a misunderstanding between C and a doctor regarding how long they would be kept nil by mouth for before their evacuation procedure. We also found that the board failed to address C’s concerns about the conduct of a sonographer (specialist in the use of ultrasonic imaging devices) in their response to the complaint. Therefore, we upheld C's 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/information-leaflets.

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

• Doctors should attend when advised that patients have passed large clots following c-section delivery and are too tender for fundal palpation.
• In cases such as this, a DATIX should be submitted by the board and the case reviewed by the hospital’s obstetric risk management team.

In relation to complaints handling, we recommended:

• In their stage 2 responses to complainants, the board should address all the issues raised and demonstrate that each element has been fully and fairly investigated, in accordance with NHS Model Complaints Handling Procedure. The board should also answer enquiries from this office in full.