Worcestershire Acute Hospitals NHS Trust

9. Miss P complains about the care and treatment she and her baby received from Worcestershire Acute Hospitals NHS Trust (the Trust) in December 2023. Specifically, she says the Trust failed to consider the risk factors in her pregnancy and schedule the birth of her baby before 38 weeks.

10. She tells us the communication around when she should deliver her baby was conflicting. She says the Trust communicated poorly with her about her baby when in the Neonatal intensive care unit (NICU). She also complains the Trust did not assess her in a timely manner and a particular member of staff was rude to her when she returned to hospital with severe back pain.

11. Miss P says from 29 weeks pregnant she experienced severe distress and anxiety for the remainder of her pregnancy. She says she was crying daily and frantically calling other hospitals to see if she could have a planned caesarean (c-section) there.

12. The Trust’s poor communication when her baby was in NICU caused Miss P anxiety and distress. Miss P says this significantly impacted her mental health, and following the birth of her baby, led to her having intrusive thoughts of her baby being harmed, and meant she did not allow people to be near her baby. She also says as she was not well, the opportunity to enjoy her newborn, and for her and her baby to bond was also taken from her. Miss P says she was diagnosed with Obsessive-Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) because of this, which she continues to suffer with.

13. By bringing her complaint to us, Miss P is seeking service improvements and a financial remedy.

14. What follows is a brief summary of events to provide context to the complaint. We do not include every detail as all parties to the complaint are aware of these.

15. Miss P’s health started to decline at 29 weeks pregnant when she was diagnosed with gestational diabetes. The Trust prescribed her metformin and insulin.

16. Miss P’s baby was breach and Miss P had strep B. Miss P says the diabetic team, doctors and midwife agreed she would need to have her baby by 38 weeks due to her uncontrolled diabetes.

17. On 13 November 2023, Miss P discussed her birth plan with one of the Trust’s consultants. We understand Miss P and the doctor disagreed about whether a c-section was the best option.

18. On 17 November, Miss P says she was seen by a different doctor who agreed a c-section was a sensible option. The doctor said they would discuss an appropriate date for a planned c-section at an MDT meeting and Miss P would hear within a week.

19. On 3 December, at 34 weeks pregnant, Miss P attended maternity triage with suspected labour and was admitted. She was given steroid injections to prepare her baby’s lungs and a sliding scale of insulin. After 12 hours, her labour symptoms resolved and she was discharged. On discharge she asked about when she would hear about her c-section date and was told to attend DAU (Day Assessment Unit) on 7 December.

20. At DAU on 7 December, staff informed Miss P that 29 December was the earliest c-section available for her, which placed her at 39 weeks pregnant.

21. We understand Miss P was concerned about going into natural labour and how this could affect her baby. She called numerous hospitals over several days to see if she could have a c-section there.

22. The Trust told her the maternity department did not have staffing capacity due to being the Christmas period which meant it would need to deliver her baby at 39 weeks.

23. On 19 December, at 37+4 weeks, Miss P had protein +++ in her urine, a headache and high blood pressure. The Trust diagnosed her with preeclampsia and so had a C-section the following day.

24. Following the birth, staff took Miss P’s baby to the Neonatal Unit (NNU) due to having Respiratory Distress Syndrome (RDS). Whilst in the NNU, her baby was moved to another area without her being told.

25. Miss P returned to hospital on 23 December with severe pain in her back. We understand she was worried about spinal damage following her c-section and so she attended the triage ward.

26. A doctor examined her and it is reported the pain was likely muscle spasms or a trapped nerve. She was treated and was able to go home.

Point One: A staff member was rude and dismissive of Miss P when she returned in pain.

30. Miss P returned to maternity triage on 23 December 2023 when she was experiencing severe back pain. She tells us how the midwife she spoke with on the phone was rude and unhelpful and told her she could attend triage if she wanted to.

31. Miss P tells us when she arrived, she heard the midwife talking about her to her colleague alleging Miss P was ‘drug seeking’ and exaggerating her pain. She tells us she was upset and went into the corridor to speak with the midwife. She said her voice was raised due to the emotion and pain she was experiencing. Miss P tells us she left triage crying and another member of staff assisted her. This member of staff arranged for a doctor to assess Miss P.

32. The Trust apologises for the midwife’s attitude towards Mis P. It says the midwife’s line manager has spoken with her and will monitor her performance in this area.

33. Our Complaint Standards states organisations should make meaningful apologies and see complaints as an opportunity to develop and improve its services and people.

34. We consider the Trust have acted in line with the above guidelines with its apology and its monitoring of this staff member.

35. Our severity of injustice scale helps us determine whether a financial remedy is appropriate in cases. The scale has six levels ranging from one off occurrences of minor pain upset and worry up to level six where often we see life changing injustices.

36. Level one on our scale explains that for low impact injustices such as annoyance, frustration, worry or inconvenience arising from a one-off incident with no lasting effects we generally consider an apology to be sufficient. In these cases, we would not usually consider a financial remedy to be appropriate.

37. We consider Miss P’s impact of frustration and distress to stem from a one-off incident when she attended maternity triage on 23 December 2023. This aligns with those described in level one in our severity of injustice scale. In these circumstances, our severity of injustice scale says an apology is enough to put right impacts like this.

38. As the Trust has already apologised for what happened and further took learning. We consider this would be the same fair and proportionate outcomes that we would find at a detailed investigation stage and therefore consider there would be no value to do so as the current remedy achieved is consistent with what we would seek. Therefore, we will not be taking any further action on it.

Point two: The Trust did not assess her in a timely manner when she returned to hospital in severe pain.

39. Miss P says attended maternity triage on 23 December 2023, concerned she had spinal damage following her c-section. She feels she was not seen by a doctor within an appropriate timeframe.

40. The records state Miss P was seen within two hours of her arrival to triage by a junior doctor and an anaesthetist. She called triage at 11:27pm on 23 December 2023, arrived at 12:55am on 24 December 2023. She was then reviewed by a specialist at 2:48am. It is recorded the doctor diagnosed Miss P’s back pain likely a trapped nerve. The records say the team were in theatre at the time she arrived.

41. We asked our adviser if it was appropriate for Miss P to have waited two hours to be assessed. Our adviser explained it was reasonable to be seen by a doctor within two hours during the night, when fewer doctors are on duty, and with priority given to urgent clinical procedures.

42. We appreciate Miss P feels she waited a long time to be seen by a doctor and we are sorry to hear of the pain and distress she was experiencing. Based on the evidence available to us, we feel the Trust has acted in line with standard clinical practice by seeing Miss P within two hours of her arrival. As we are not able to identify a failing we will therefore not be taking this part of the complaint process any further.

Point three: The Trust failed to consider the risk factors in Miss P’s pregnancy and schedule the birth before 38 weeks.

43. Miss P says she had a high-risk pregnancy and was told by healthcare professionals she would need to deliver her baby by 38 weeks. Miss P’s risk factors were gestational diabetes (GDM), her baby being breach and her history of anxiety. She told us her diabetes nurse was concerned as she was on both metformin and insulin, she needed to have her baby delivered prior to 38 weeks.

44. In its response to Miss P, the Trust apologised it was unable to bring forward the date of her caesarean (c-section) as the Trust was at capacity for sections due to the impending medical strikes and Christmas period. It acknowledges the maternity team can improve its communication to women in its care and also how it can better arrange section lists to create additional capacity.

45. The size and breech position of the baby along with Miss P’s GDM and anxiety, are the factors Miss P feels the Trust should have considered when deciding on the most appropriate time for Miss P to have her baby delivered.

46. We asked our adviser what should have happened in Miss P’s situation. The adviser explained Miss P’s CTGs (cardiotocographs) showed no concerns around the featal heart rate pattern, the baby was on the nineth centile, meaning the baby was larger than expected, and which is often associated with gestational diabetes (GDM).

47. Our adviser says NICE guidelines state doctors should advise women with gestational diabetes to give birth no later than 40 weeks plus six days. The guidelines also state doctors should consider elective birth before 40 weeks plus six days for women with gestational diabetes who have maternal or fetal complications.

48. We have seen the Trust appropriately considered Miss P’s risks (GDM, 90th centile baby and breech position) during an appointment on 11 December 2023 and planned to deliver Miss P’s baby at 39+6 weeks. This was therefore within guidelines and shows no indication something went wrong.

49. Additionally, from the clinical advice received we understand a person suffering with anxiety will often experience heightened anxiety during pregnancy. They say considering GMC guidance, the Trust should have considered how it communicated its decision to not bring forward her planned c-section.

50. GMC guidance states when doctors are providing clinical care, they must adequately assess a patient's conditions, taking into account their history and relevant psychological, spiritual, social, economic, and cultural factors as well as the patient’s views, needs, and values.

51. We feel it would have been better to explain reasoning for and against bringing forward Miss P’s c-section before 39 weeks and providing assurance.

52. The Trust’s reason of not having capacity for Miss P to have an earlier c-section would have understandably caused Miss P concern. The Trust has taken learning form this matter and recognised it can improve its communication with women and their families and have apologised to Miss P.

53. Our ‘NHS Complaints Standards’ explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’ Further, it says we expect organisations to ‘take action to make sure any learning is identified and used to improve services. Finally, our standards say organisations should be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’.

54. The Trust apologised in its response and has explained its actions to improve its communication with pregnant women and their families. That said, we do feel the Trust could do more to put right the impact Miss P experienced.

55. Miss P tells us the distress and worry that she experienced has severely affected her mental health at the time and even now as she was diagnosed with Obsessive-Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) because of this situation.

56. We do not wish to lessen the impact Miss P has experienced. We do recognise at the time, these matters could have likely contributed towards an overall negative experience with mental health and wellbeing as a result of the experience.

57. We would not be able to definitively say with any robust and definitive conclusion if this was the sole cause of Miss P’s PTSD and OCD or whether pregnancy and childbirth also impacted her mental health.

58. We are then left with the injustice of distress and worry Miss P experienced. We will explain how we have considered this impact later in our statement.

Point four: The Trust communicated poorly with Miss P about her baby whilst in NNU.

59. Miss P says after the birth of her daughter she developed Respiratory Distress Syndrome (RDS) and was transferred to the Neonatal Unit (NNU) at two hours’ old. Miss P says the Trust staff communicated poorly with her, specifically that B was moved to different bays on NNU without her being told. Miss P says she was not informed about the investigations D had and she did not feel staff always gained her consent for tests.

60. In its response, the Trust has apologised sincerely for this failing and for the lack of communication and the impact this had on Miss P at the time. The Trust explains how Miss P’s concerns have been shared with the Matron for NNU and also with the rest of the staff for wider learning and understanding to address issues and improve services.

61. Our ‘NHS Complaints Standards’ explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’ Further, it says we expect organisations to ‘take action to make sure any learning is identified and used to improve services. Finally, our standards say organisations should be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’.

62. We consider the Trust have acted in line with our NHS complaints standards. It acknowledged the mistakes and apologised for the impact it had. It also correctly took this as an opportunity to learn and improve its service. In line with the Ombudsman’s Principles of Remedy we consider this fair, reasonable and proportionate.

63. That said, we felt the Trust needed to do more to recognise the impact the poor communication had on Miss P. Miss P has suffered significant distress and worry when she visited her daughter in NNU to find her not where she was before. Miss P says the poor communication around D’s care and treatment significantly impacted her mental health, and following the birth of her baby, led to her having intrusive thoughts of her baby being harmed. She says it meant she did not allow people to be near her baby.

64. We will explain how we have considered this impact below.

Impact of point three and four

65. We have considered the joint impact of both points three and four. When we approach an injustice, we use a range of tools to better understand these. We first consider on an individual basis the complainant’s lived through experience by discussing this to get a better understanding.

66. In support of this we rely on the Ombudsman’s severity of injustice scale (SOIS) – an open and transparent scale that has six bands of various injustice from level one frustrations and short-lived issues to level six where we see profound impact often characterised by potential loss of life.

67. We also consider similar complaints we have upheld and the range of recommendations that have been made through our internal ‘typology of injustice scale’ to help ensure anything we may consider as a remedy is consistent with precedent already set.

68. We also conduct precedent checks into organisations to look if the themes of a complaint are indicative of wider systemic issues or known failings which we have investigated before and can influence our thinking on consideration of wider remedy and learning.

69. Further to all of this, advised by our own policy on case working (called the service model) we look to resolve complaints as effectively as we can or with minimal intervention. We refer to this as seeking a ‘resolution’ to a complaint.

70. Miss P is seeking service improvements and a financial remedy. We asked what financial remedy miss P had in mind and note she sought a financial remedy only if it was applicable.

71. Using our severity of injustice scale (our scale), the impact Miss P claims appear to be in line with a level two of our severity scale of injustice. This is because the injustice was more serious but only took place once or was of a relatively short duration. In this case, an apology alone is not enough.

72. As part of our work, we contacted the Trust. We explained our emerging thinking and explored the opportunity for a resolution given the distress and worry Miss P experienced during the final stages of her pregnancy from its poor communication, we felt it needed to do more to put the complaint right.

73. The Trust offered a financial remedy of £500 in recognition of the distress.

74. Taking all this into account, we are satisfied this provides a remedy that is fair and with proportionality and reasonableness. It has apologised, taken learning from the complaint and offered an appropriate financial remedy in line with our severity of injustice scale. This is in line with all the outcomes Miss P wanted by bringing her complaint to us.

75. We do not consider the complaint requires a detailed investigation as it is likely the outcomes we would achieve through that process have already been made now. We are satisfied we have been able to successfully resolve this part of her complaint.

Conclusion

76. We would like to thank Miss P for taking the time and effort in bringing her complaint to us and we wish her, her daughter well.

77. We have included the next steps on the cover letter for her to receive the financial redress offered by the Trust.

1. We have carefully considered Miss P’s complaint about the Trust. We are sorry to hear she feels let down by the Trust in her pregnancy as well as in its care provided to her daughter whilst D was in the neonatal unit (NNU). From what she has told us, this was a distressing time and made her feel she was unable to enjoy her pregnancy and time with her newborn baby.

2. Based on the evidence we have considered, we have seen the Trust have followed guidance when considering Miss P’s risk factors in her pregnancy and in scheduling the birth when she was 39 weeks pregnant.

3. In its response, the Trust has acknowledged its communication with Miss P should have been better and apologises for this. It has also explained her complaint has been shared with staff for wider learning and understanding to prevent a similar situation happening. That said, we felt the Practice needed to do more to put things right.

4. The Trust has offered £500 (five hundred) to recognise and put right the distress and impact on Miss P. We are satisfied this proposed action is fair and appropriate to resolve this complaint. We explain this in more detail throughout our statement.

5. Miss P also complains about the care and treatment she received when she returned to hospital on 24 December with severe back pain. Based on the evidence available to us, we can see the Trust assessed Miss P in an appropriate time frame and will not be taking further action on this part of the complaint.

6. Miss P felt a member of staff was rude to her when she returned. We fully appreciate how distressing it would have been for Miss P to experience this. We feel the Trust have done enough to put right the complaint. We have decided not to consider this part of the complaint further.

7.

8. We recognise how important this complaint is to Miss P, and we would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint and provides reassurances that the Trust followed relevant guidelines in its consideration of her risk factors during pregnancy.