Barts Health NHS Trust

4. Ms O complains that on 9 October 2023, during a foeticide procedure, the Trust failed to provide appropriate emotional support and privacy before, during, and after the procedure, and did not show compassion towards her circumstances.

5. She adds that the doctor who completed the procedure did not have the required experience to carry out this procedure in such uncommon and exceptional circumstances.

6. She also complains that when she delivered her baby on 10 October 2023 the Trust:

• would not discuss options for the birth of her baby and refused to carry out a caesarean section • gave her a dose of misoprostol that exceeded national guidelines, failed to advise her of this, and failed to take appropriate precautions to safeguard her health after administering this dose • failed to carry out appropriate examinations and monitor her contractions • refused to provide appropriate pain relief during childbirth and delayed in attempting to insert an epidural • failed to notice she was actively delivering her child whilst an anaesthetist was attempting to insert an epidural. The anaesthetist forced her to sit forwards, which was an inappropriate posture when delivering a child.

7. Ms O explains these failings caused her additional intense distress at an already very distressing time in her life. She describes the decision to go ahead with the foeticide as one of the worst days of her life, and the Trust’s actions and inaction significantly exacerbated this. She adds that she experienced extreme levels of pain, terror, and has developed Post Traumatic Stress Disorder (PTSD) as a result of her experience.

8. She also explains that the clinical failings on 10 October caused a severe haemorrhage, cervical and clitoral tears, and an acute kidney injury. She had to have emergency surgery whilst awake to stop the haemorrhage and repair the injuries to her reproductive organs. She also developed nerve damage in her foot. This caused ongoing pain and discomfort for over a year after the surgery was completed.

9. Ms O also complains that the Trust was not candid in its responses to her complaint, and the same doctor who supervised the foeticide also led the investigation into her complaint. She says this meant the investigation was not impartial, caused her to lose faith in the Trust’s complaint handling, and compounded the distress of the clinical failings.

10. Ms O would like the Trust to implement service improvements to prevent the same failings happening again. She would also like the Trust to compensate her for the physical injury and distress arising from its failings.

11. Ms O became pregnant in early 2023. In April, she attended her first antenatal appointment. Obstetric ultrasounds in June and July documented that the foetus had club feet on both sides and abnormal positioning of the joints. It was also noted during her pregnancy there was a high risk the foetus may have chromosomal abnormalities.

12. On 5 September, Ms O had a third trimester ultrasound. The clinician noted the foetus was very small – in the 10th centile (meaning it was smaller than 90% of foetuses at this stage of the pregnancy). She underwent an amniocentesis (analysis of the fluid surrounding the foetus) on 26 September.

13. The results of the amniocentesis revealed a genetic abnormality that could cause developmental delays, affect her baby’s growth, and abnormalities to her baby’s musculoskeletal system. Ms O made the heartbreaking decision to undergo a foeticide procedure to prevent unnecessary suffering to her child.

14. Ms O had the foeticide procedure on 9 October at Hospital A. She was advised she would need to deliver her baby at Hospital B the following day.

15. On 10 October, Ms O met a bereavement midwife outside Hospital B’s maternity service and was escorted onto the ward. She delivered her baby later that day. He was stillborn, as expected, following the foeticide procedure.

16. Following her labour, Ms O experienced a post-partum haemorrhage. This is a serious medical complication following childbirth that can be fatal. She lost 1.7 litres of blood and required blood transfusions. Following surgery, Ms O developed an acute kidney injury due to blood loss. She also sustained physical injury as a result of the birth.

17. Ms O was discharged home on 14 October. She required follow up care due to positional nerve damage and to ensure her kidney injury was resolving.

9 October 2023: Hospital A

Emotional support

21. The Royal College of Obstetricians and Gynaecologists has published guidance on the termination of pregnancies for foetal abnormality (the Medical Termination guidelines). In line with this guidance, any person undergoing this procedure should be given a private room with facilities for their partner to stay. This guidance says that all relevant staff should be aware of the woman’s history and management plan to avoid the need for them to explain the situation repeatedly to different staff members.

22. Ms O says that when she attended the hospital on 9 October nobody seemed to know why she was there. She adds that she had to explain she was there for a foeticide procedure to several different receptionists, which was very distressing.

23. Ms O also says she and her partner were left sitting in the waiting room for a long period of time. During this time, she was sitting amongst other pregnant women and, after the procedure, she was left in the procedure room to discuss the next steps.

24. In its complaint response dated 29 May 2024, the Trust apologised for Ms O’s experience and acknowledged there had been delays. It explained that because the foeticide procedure had a legal timeframe it must be completed within, fitting her appointment into the clinic that day led to overbooking. It added it was not always feasible to provide private rooms for all patients.

25. We acknowledge the pressures on NHS maternity services and the additional demand posed by an unforeseen and urgent patient needing to be seen in the clinic. That said, undergoing a foeticide procedure, especially at such a late stage in pregnancy, is an emotionally harrowing experience for anyone to go through. This should have been front of mind for the service when providing this care to Ms O and appropriate arrangements for emotional support should have been arranged in line with the Medical Termination guidelines.

26. The Trust demonstrated a lack of forethought and planning regarding the emotional support Ms O needed on 9 October. The provision of a private room, making staff aware of the reason for her appointment, and allowing her to wait in a room she did not have to share with other pregnant people could have been provided without considerable notice or resources.

27. We have found the Trust did not do enough to make sure Ms O received emotional support in line with the Medical Termination guidelines and this amounts to service failure.

Clinician expertise 28. With regards to the expertise of the doctor carrying out the foeticide procedure, our Obstetrics Adviser explained that overall responsibility for the procedure fell to the consultant supervising it.

29. The GMC’s Good Medical Practice guidelines outline that more experienced doctors should be prepared to contribute to the training of doctors and ensure all staff have appropriate supervision.

30. There are no national guidelines outlining the specific experience required to carry out this procedure. This procedure is not uncommon, though it is rare for it to occur as late as in Ms O’s case. It was the supervising consultant’s discretion as to whether it was appropriate for a registrar (a doctor undergoing specialist training in their area of medicine) to undertake this procedure with supervision, even in the circumstances of a very late-stage termination.

31. We recognise how concerned Ms O is about the expertise of the doctor, and how distressing this procedure was for her. It is essential that registrars gain experience with all procedures, including those taking place in uncommon circumstances. This ensures the NHS will have competent specialists in the future. There are no guidelines to say this procedure should not have been undertaken by a registrar, and doing so was at the discretion of the supervising consultant.

32. We have found that it was appropriate for the supervising consultant to take the view that doctor was competent to undertake the procedure whilst supervised. This does not amount to service failure, though we acknowledge that Ms O disagrees with this conclusion.

10 October 2023: Hospital B

Birth options 33. The Royal College of Obstetricians and Gynaecologists’ guidance ‘late intrauterine foetal death and stillbirth’ (the Stillbirth guidelines) say that a careful, sensitive discussion and joint decision-making should take place when discussing delivery options. This should include the implications of caesarean delivery for future pregnancies/childbirth. The guidance also says decision-making should be based on a discussion between the parents and an obstetrician, and that staff should be considerate of parents’ wishes and beliefs when discussing the mode of birth.

34. NICE guideline NG207 (inducing labour) also says ‘in the event of an intrauterine foetal death, if the woman appears to be physically well, her membranes are intact and there is no evidence of infection or bleeding, discuss the options for birth . . .and respect the woman's decision’.

35. Section 1.2.32 of NG207 is also very clear that for women experiencing intrauterine foetal death, the discussion of the birthing method is very important. This is because the induction of labour for women who have previously had a caesarean section can lead to uterine rupture. This is life-threatening complication where the wall of the uterus tears open and requires immediate surgery to save the mother’s life. Ms O had previously had a caesarean section.

36. On 10 October a bereavement midwife documented that Ms O was ‘quite certain she [didn’t] want a [caesarean section]’ but it is unclear whether this had been formally offered as an option, or how this discussion arose. The note also said this would be discussed further with a consultant. This was appropriate as the Stillbirth guidelines say that the discussion around birth options should take place between the parents and an obstetrician.

37. Later, a consultant obstetrician documented a ‘long discussion’ but there was no documentation that the option of a caesarean section was discussed, nor was there any documented discussion around the risks of a caesarean section compared to a vaginal birth. Whilst the Stillbirth guidelines acknowledge that a vaginal birth is recommended for most women who want to optimise future pregnancy outcomes, this should have been fully discussed with Ms O and adequately documented.

38. We have found the documentation of discussions with Ms O about her birth options fell below the standard set out in the national guidance. The Trust’s initial discussion with her on 9 October did not include any plan for the induction of labour, nor any discussion of her preferences. There is also no documented evidence the Trust discussed birth options with Ms O at any point, nor that it considered, offered or discussed a caesarean section.

39. Ms O’s account, as outlined in her original complaint to the Trust, is that she was ‘not ever offered a reasonable discussion around any available options, or why there were no options for birth’. She also said ‘there was also no discussion around any options available, or lack of options’. She added ‘it seemed that everyone who discussed it with [her] on 10 October thought someone else had already explained’.

40. We have found the Trust failed to appropriately discuss and document birth options with Ms O and her partner. This falls short of the Stillbirth guidelines and NICE guideline NG207, and amounts to service failure.

Misoprostol 41. We recognise Ms O strongly feels the dose of misoprostol administered to her was too high. There are no national guidelines which recommend a dosing regimen for misoprostol in women over 28 weeks’ gestation when they have previously had a caesarean section.

42. There is no dose of misoprostol that is considered safe for women in these circumstances and both national guidelines and the manufacturer’s guidelines are clear about this. This has made our consideration of this matter complex, and we have relied on our Obstetrics Adviser’s clinical expertise to reach a view on the balance of the evidence.

43. NICE guideline NG207 outlines the methods of induction for a woman in the case of an intrauterine foetal death when the woman has previously had a caesarean section. This outlines the risk of uterine rupture when using drugs, including misoprostol, to induce labour. This is also supported by the Stillbirth guidelines, which outlines the same risk.

44. NG207 recommends that clinicians use the manufacturer’s guidance when using misoprostol. The guidance published by the manufacturer states that the maximum dose within a 24-hour period is 200 micrograms, but the dosing regimen outlined in these does not cover women in Ms O’s circumstances. The recommendations for research section of NG207 is clear that there is not enough evidence to recommend a dosing regimen for women in Ms O’s circumstances.

45. The Stillbirth guidelines recommend developing and following a local protocol for women over 28 weeks gestation with a previous caesarean section. This is because there is no agreed upon dosing regimen in these circumstances.

46. In its complaint response, the Trust noted it had developed a local protocol based on published clinical data, in line with the Stillbirth guidelines. It is relevant to note that the Stillbirth guidelines in place when Ms O was induced were published in 2010, 13 years prior to these events. An updated version of these guidelines was published the following year, which indicates higher doses of misoprostol up to 200 micrograms are generally safe.

47. In the absence of any national guidelines on dosing regimen, and the fact 200 micrograms within 24 hours is considered safe, the Trust’s rationale for allowing for a higher single dose within its local protocol was not a failing. In its complaint response the Trust said NICE guideline NG207 cited a lack of evidence for the safest method to induce labour in Ms O’s circumstances, which is correct. It also explained the Trust had used published data to develop a local protocol in the absence of explicit directions from national guidelines.

48. In light of the absence of national guidelines and the explanation of its local protocol by the Trust, we do not consider the dose of misoprostol amounts to service failure. The dose administered was not an error, it was in line with the Trust’s protocol. The Stillbirth guidelines recommend developing a local protocol, and there is nothing to indicate the Trust’s protocol was unsafe.

49. Although the dose of misoprostol was not unsafe in and of itself, the Trust failed to document any discussion with Ms O regarding the safety of induction for women in her clinical circumstances, specifically the risk of uterine rupture. This is recommended by both NICE guideline NG207 and the Stillbirth guidelines.

50. The Stillbirth guidelines also recommend closely monitoring the woman for features of scar rupture. This includes observing for clinical features of early scar dehiscence (partial re-opening), such as atypical pain, vaginal bleeding, and blood in urine.

51. We have found that whilst the dose of misoprostol does not amount to service failure, the Trust failed to advise Ms O that there was no safe dose of this drug for women in her circumstances, and appropriately discuss the risks associated with this. It also failed to take adequate safety precautions regarding the risk of uterine rupture. This is because it did not discuss the risk of uterine rupture with Ms O before using misoprostol to induce labour. There was also no documented consideration of the risk within her notes, and the Trust did not document a robust plan to monitor Ms O for signs of uterine rupture.

52. Whilst, fortunately, Ms O did not experience a uterine rupture, the Trust’s failure to discuss and document a plan for monitoring this risk amounts to service failure.Monitoring 53. NICE guideline NG207 recommends that if a woman with an intrauterine foetal death chooses to induce labour, clinicians should follow the recommendations on monitoring of uterine contractions set out in NICE guideline NG229 (foetal monitoring in labour) and provide one-to-one midwifery care of the woman during labour and birth.

54. One-to-one midwifery care means women should have the support of the same midwife throughout active labour. One-to-one care does not mean a midwife should be present at all times; however, NICE guideline NG235 (intrapartum care) recommends that once a woman is in established labour, she should not be left alone except for short periods or at her request.

55. NICE guideline NG229 recommends using a tocodynamometer to record contraction frequency and length. A tocodynamometer is a device used during labour to measure the frequency, duration, and intensity of uterine contractions. This enables clinical staff to monitor the stages of labour and indicate when a woman is progressing from the latent stage to delivery.

56. NICE guideline NG235 recommends half hourly documentation of the frequency of contractions in the first stage of labour. The established first stage of labour is defined as when there are regular contractions and there is a gradual opening of the cervix (progressive dilation) over 4cm. Prior to this, a woman is considered to be in a latent stage of labour.

57. A portogram (a tool used to monitor the wellbeing of a mother and baby during labour) is also recommended once a woman is in the first stage of labour. These guidelines do not caveat that this should only be used when the baby is alive. Our Midwife Adviser confirmed it is good practice use a portogram, even when a baby is no longer alive.

58. There are no guidelines as to how often contractions should be monitored when a woman is in the latent stage of labour. However, our Midwife Adviser explained that routine, established good practice would be to monitor women who are high risk every hour. Ms O was at high risk due to her previous caesarean section and having an induction of labour following a late-stage termination.

59. Establishing the progression of dilation involves undertaking vaginal examination. This should happen every four hours in the first stage of labour. There should also be half-hourly monitoring of contractions alongside the use of the portogram to monitor the mother’s wellbeing.

60. Ms O’s medical records indicate the most likely time she entered established first-stage labour was at 6.15pm. This is because she was having 2-3 contractions every 10 minutes, meaning her contractions were regular. Prior to this, at 5.19pm, her contractions were less frequent (once every 10 minutes).

61. It is difficult to know whether Ms O was more than 4cm dilated at 6.15pm as no vaginal examination was documented at that time. This was not service failure, however, as NICE guideline NG235 does not specify how soon this should happen. We can see a vaginal examination was offered at 6.34pm, but Ms O declined this due to the level of pain she was experiencing. She then consented to this at approximately 6.45pm.

62. Ms O’s labour progressed rapidly, and she delivered her child an hour after she most likely entered established labour. This is known as precipitous (or precipitate) labour, which is defined as a delivery that occurs less than three hours after the regular onset of contractions. Precipitous labour is unusual and carries a higher risk of complications for the mother and child.

63. The Trust should have used a tocodynamometer and portogram, as recommended by NICE guideline NG235, to monitor Ms O’s wellbeing, contractions and the progression of her labour. This was especially important given that Ms O was at risk of uterine rupture, and these tools can help to detect clinical indicators that a uterine rupture may have occurred. This did not happen, and it amounts to service failure.

64. We have also found the Trust failed to recognise the rapid progression of Ms O’s active labour from 6.15pm. This was more likely than not a result of failing to adequately monitor her contractions and the progression of her labour.

65. When a woman is in the first stage of labour, she should not be left alone except for short periods or at her request. The guidelines do not outline how a ‘short period’ is defined; however, the clinical notes indicate a midwife was consistently present aside from some short periods where they needed to undertake tasks essential to supporting Ms O with her labour and delivery.

66. The midwife documented leaving the room with the anaesthetist present whilst they obtained further pain relief for Ms O at 6.55pm. These were obtained from the controlled drugs cabinet and the midwife returned to the room at 7.12pm. Obtaining controlled drugs usually requires a second clinician to witness dispensing the drug due to the tight regulation of these types of medications. This means it can take longer than obtaining non-controlled medications because two members of staff need to be available to complete this task.

67. There was a four-minute window between the midwife documenting they were back in the room and Ms O delivering her child. Ms O’s account is that the midwife was not present when she delivered her child; however, her medical records document that the midwife was present at the time she delivered her baby. We can see the midwife left the room for approximately 17 minutes prior to Ms O delivering her baby. This did not depart from NICE guideline NG235, which allows for midwives to leave the room for short periods. 17 minutes was not an unreasonable period given the time needed to dispense a controlled drug.

68. What we can say, however, is that had the Trust adequately monitored the progression of Ms O’s labour, it may have recognised its rapid progression and that she may have been closer to delivering her child than would normally be expected. That said, our Obstetrics Adviser has said that it would have been very difficult for the staff to have predicted just how rapidly Ms O would deliver her child even if she had been monitored in line with national guidance. Her labour was unusually rapid even for precipitous labour.

69. We have found the Trust failed to carry out appropriate examinations and monitor Ms O’s contractions in line with NICE guideline NG235. This amounts to service failure.

Pain relief 70. NICE guideline NG235 outlines the following recommendations for pain relief when a woman is in labour:

• ensure inhalational analgesia (pain relief that is inhaled) is available in all birth settings • ensure pethidine, diamorphine, or other opioids are available • consider patient controlled analgesia (PCA) as an option for women who want ongoing relief during labour and birth • after discussion of risks and benefits, if a woman requests regional analgesia (such as an epidural), support her decision.

71. Ms O was offered a cannula for PCA at 1.40pm but declined this, stating she only wanted a cannula sited ‘if necessary’. The Trust explained this could be inserted later, but that this may be in an emergency and could delay pain relief. She was offered a cannula for PCA again 3.47pm but declined this for the same reasons. The clinician noted they advised Ms O against declining the cannula. We acknowledge Ms O disagrees with the clinical narrative documented at the time.

72. Ms O’s medical records indicate she quested oral pain relief at 5.19pm and this was administered at 5.30pm. She was also offered inhalational analgesia (Entonox). The oral pain relief was paracetamol and dihydrocodeine (an opiate drug). The midwife noted Ms O wanted to see if the Entonox was effective before having further pain relief.

73. At 5.45pm Ms O began considering PCA. The midwifery staff discussed pain relief with an anaesthetist and senior midwife, who agreed PCA was the best choice rather than an epidural as it was uncertain when Ms O would deliver.

74. At 6pm Ms O consented to PCA, and this was inserted at 6.15pm. At 6.30pm the PCA pump (the machine that delivers the pain relief via the cannula) was not working properly and the midwives were attempting to resolve this. The midwives discovered the cannula had fallen out and inserted a second cannula. The pump was started at 6.34pm.

75. An epidural was discussed at 6.45pm and again at 6.55pm. At 7.12pm the anaesthetist attempted to insert the epidural. Both our Midwife and Anaesthetist Advisers noted that an epidural could have been offered sooner. It is unclear why this was not discussed with Ms O at 5.45pm when the anaesthetist and senior midwife were considering an epidural.

76. NICE guideline NG235 states that clinicians should be aware of their own beliefs around coping with pain during labour and ensure care supports the woman’s choice. Discussing this without involving Ms O means her choice with regards to an epidural was not considered as part of this conversation. Rather, the decision appears to have been made on the basis of the clinicians’ belief that PCA was more appropriate.

77. Our Anaesthetist Adviser explained that insertion of an epidural could have been considered before the onset of contractions so that it could have been given before contractions began. That said, prior to the onset of contractions Ms O had declined a cannula, stating she did not want it to be sited for a long period if it felt uncomfortable and wasn’t necessary. The insertion of a cannula is necessary prior to inserting an epidural because blood tests need to be carried out prior to insertion. This means inserting an epidural was not possible until a cannula had been inserted, which Ms O declined prior to the onset of her contractions.

78. From the point at which Ms O consented to PCA and the possibility of an epidural was discussed, her labour progressed rapidly. Our Anaesthetist Adviser explained the cannula needed to be inserted and blood tests taken before the epidural could be inserted. They also explained that an epidural takes some time to begin working. In the timeframe the Trust had to act within, with hindsight, it is unlikely an epidural would have benefited Ms O.

79. We have found Ms O was offered the full range of options for analgesia during her labour. Ms O has said she declined a cannula because she wanted to be move around comfortably, meaning she did not have one inserted until 6pm. She had been advised that inserting the cannula later may be more challenging and delay pain relief and was also later advised to reconsider insertion of the cannula but declined.

80. We have found Ms O’s choices around pain relief were mainly guided by her preferences. This was in line with NICE guideline NG235, which states the clinicians should supports the woman's choices when considering pain relief. We acknowledge Ms O disagrees with the clinical narrative documented by the staff at that time.

81. The discussion about the epidural that took place at 5.45pm should have considered Ms O’s preference and this did not happen. This reflects a lack of consideration of Ms O’s wishes and preferences. Following this conversation, the anaesthetist requested blood tests in anticipation of an epidural at 6pm, which were undertaken as soon as the cannula was inserted at 6.15pm. The records indicate Ms O requested an epidural at 6.55pm and the anaesthetist discussed this with her at that time.

82. NICE guideline NG235 recommends an epidural only when the woman requests this. Although there was a missed opportunity to discuss this with Ms O at 5.45pm, the Trust still proactively undertook blood tests in anticipation of this request. This meant the epidural could be sited quickly at Ms O’s request. Following her request for an epidural, there was no delay in proceeding with this, with the anaesthetist attempting to site the needle at 7.12pm.

83. The evidence shows that the pain relief offered during Ms O’s labour was in line with NICE guideline NG235 and was mainly guided by her preferences. Whilst insertion of an epidural may have been able to take place sooner in anticipation of the onset of contractions, this could not happen because Ms O had declined a cannula. Ms O was advised declining the cannula could delay pain relief and was advised to reconsider this decision. Once Ms O had consented to the cannula and an epidural, there was no delay in offering and undertaking this procedure.

84. We have found no service failure relating to pain relief, overall. The pain relief offered was in line with NICE guideline NG235 and, in the main, appropriately took account of Ms O’s preferences. We note, however, that the discussion around pain relief options that took place at 5.45pm should have included Ms O. Whilst this does not appear to have impacted on the pain relief provided, this reflects a lack of consideration of her views, preferences and experience.

85. There is also no indication that there was a delay in inserting an epidural. The Trust could not do this sooner because Ms O had declined a cannula.

Position during labour 86. NICE guideline NG235 states that women can adopt whatever positions they find comfortable throughout labour, except lying flat on their back. As outlined earlier in the report, the Trust failed to appropriately monitor Ms O’s contractions and the progression of her labour, which caused it to miss how rapidly her labour was progressing.

87. Our Obstetrics Adviser explained that it was appropriate to insert the epidural at this time, and it was unexpected, though not unheard of, for her to deliver her child so rapidly. This is even in the context of precipitous labour, which can still take up to three hours until delivery. This means that even if the precipitous labour had been identified via appropriate monitoring, such a rapid delivery would still likely have been unexpected.

88. We recognise Ms O feels strongly that had she not been sat forwards during her delivery, her post-partum injuries could have been avoided.

89. We do not consider the Trust forced Ms O to adopt an inappropriate or unsafe position whilst delivering her child. Our Anaesthetist Adviser explained that the Trust’s anaesthetist could not have anticipated just how quickly she would have delivered her child between the epidural being requested and its insertion. Even in the context of precipitous labour, the delivery was unusually rapid. Attempting to insert the epidural at this time, and the position Ms O was in at the time she delivered her child was not service failure.

Complaint handling 90. Our NHS Complaint Standards provide a framework for NHS services to provide a good standard of complaint handling. In line with these standards the Trust should have:

• if possible, ensured the person investigating the complaint had not been involved in the issues raised • given a clear and balanced account of what happened based on established facts and referencing relevant policies and guidelines • been open and honest where it found things went wrong • treated Ms O with empathy and respect, and used her feedback to improve its services.

91. Ms O met with clinicians in February 2024 to discuss her concerns about the care she received. She explains this resolved some of her concerns, but there were outstanding issues it was not possible to address during that meeting. She raised a complaint about her care in March 2024.

92. The Trust issued a response on 29 May. The Trust’s response was compassionate and acknowledged Ms O’s experience and her distress on 9 October. It also outlined some steps it intended to take to improve the support provided to women when undergoing a foeticide procedure. It did not, however, say whether or not the service fell below the expected standard, nor reference any local or national guidelines.

93. The Trust acknowledged there was a delay in Ms O being seen by a doctor on 10 October, confirmed this was not in line with the service it aimed to provide, and that it was taking steps to address this. It also apologised about the way in which her interactions with the staff that day made her feel.

94. The Trust did not comment on whether anything went wrong regarding the discussion of birthing options, pain relief, and the monitoring of her labour. It did apologise for her experience and outline steps it would take to improve the service.

95. The investigation was carried out by two consultants in obstetrics and gynaecology and a specialist matron (midwife) in intrapartum care. We have confirmed the names of all clinicians who provided care to Ms O on 9 and 10 October and these clinicians were not involved in the events which took place.

96. We can see the Trust took Ms O’s complaint seriously and responded in a compassionate manner that attempted to seek ongoing improvement of its maternity services. This was in line with our NHS Complaint Standards.

97. The Trust missed an opportunity to be clear about whether it had found things had gone wrong. Its internal complaint handling documentation reflects that it upheld Ms O’s complaint, which indicates it had acknowledged things had fallen short of what should have happened. The written response to her, however, did not reference this. It also did not reference what standards it met or did not meet. Whilst this was a shortfall in complaint handling, this does not amount to service failure overall.

Impact 98. Ms O says that the lack of emotional support provided by the Trust on 9 October caused her additional intense distress at an already very distressing time in her life. She describes the decision to go ahead with the foeticide as one of the worst days of her life and says the Trust’s actions and inaction significantly exacerbated this.

99. We have found the additional distress described by Ms O stems directly from the failure to provide emotional support during the foeticide procedure.

100. With regards to the failings identified in the care provided on 10 October, the failure to discuss birthing options caused Ms O additional distress and uncertainty during what would, understandably, already be an incredibly difficult and distressing experience for her.

101. We asked our Obstetrics Adviser about the clinical impact of the failings identified on 10 October. They explained the most likely cause of the clinical trauma and haemorrhage was the rapid progression of Ms O’s labour and the spontaneous delivery of her child without a ‘hands on’ approach to delivering the head.

102. Our Obstetrics adviser also explained that this spontaneous delivery was difficult to predict or avoid given the unusually rapid speed of events, and the plan for epidural anaesthesia. Whilst it was appropriate for the anaesthetist to attempt to insert the epidural at that time, the positioning would have made monitoring the progression of her labour challenging. From the perspective of our Obstetrics, Midwife and Anaesthetist Advisers, the clinicians could not have reasonably known Ms O would deliver her child so rapidly, even if monitoring and safeguarding actions had been in line with the expected standard.

103. Whilst we recognise Ms O experienced significant clinical complications from this birth, it is more likely that not these complications arose due to the extremely rapid progression of her labour and delivery, not the failings identified.

104. We recognise, however, that the failure to monitor and safeguard Ms O more likely than not caused her significant distress and to feel unsupported and unsafe during her delivery. She says she has developed PTSD as a result of the failings identified. We cannot robustly conclude these failings directly caused her to develop PTSD as the events were traumatic in and of themselves, and would likely have been so even if the failings had not occurred.

105. What we can say, however, is that these failings exacerbated an already difficult and distressing set of circumstances, causing Ms O fear, distress, and uncertainty during her labour.

106. The Trust has not sufficiently acknowledged what went wrong or taken appropriate steps to put things right. It has agreed with our findings and recommendations.

1. We have found that Barts Health NHS Trust (the Trust) failed to:

• ensure Ms O received appropriate emotional support in line with national guidelines when undergoing a foeticide procedure on 9 October 2023 • discuss birth options with Ms O, including the option of a caesarean section • take appropriate safeguarding actions after administering misoprostol • carry out appropriate examinations and monitor her contractions whilst she was in labour.

2. We have also found the Trust:

• allowed a speciality trainee doctor to undertake the foeticide procedure, which was appropriate and at the discretion of the supervising consultant • administered a dose of misoprostol that did not exceed the manufacturer’s guidelines and was in line with its local policy. The local policy aligned with clinical data around higher doses of misoprostol • offered pain relief in line with national guidelines and did not delay in inserting an epidural • did not force Ms O to adopt an inappropriate or unsafe position when delivering her child • handled Ms O’s complaint in line with our NHS Complaint Standards, though there was a shortfall in communicating where the Trust had concluded its service had fallen below the expected standards.

3. These events exacerbated an already difficult and distressing set of circumstances, causing Ms O avoidable fear, distress, and uncertainty during her labour. We partly uphold this complaint.