University Hospitals Birmingham NHS Foundation Trust

4. Ms D complains that when she was giving birth to her daughter on 9 August 2022, a doctor at the Trust:

• performed an episiotomy without getting her informed consent • forcibly removed her placenta • gave her stitches without any pain relief • made incorrect medical records about the birth.

5. She also complains that between 9 August 2022 and 29 April 2024 the Trust handled her complaint with a long delay and did not provide her a debrief.

6. Ms D tells us that she suffered excruciating pain when the doctor forcibly removed her placenta, and gave her stitches without pain relief. She says she was diagnosed with pelvic floor dysfunction after the birth, which she believes was caused by things going wrong during the birth. She explains that this condition causes severe pain, impacts her intimacy with her partner and significantly reduces her quality of life.

7. Ms D says she was diagnosed with PTSD, postnatal depression, and severe anxiety and has had intermittent suicidal thoughts due to the traumatic birth of her daughter. She says that the episiotomy without her consent contributed to her psychological symptoms, and tells us she feels violated. She tells us that she has had therapy and needs ongoing mental health support. Ms D tells us that the issues with the birth has made vaginal examinations and treatments very difficult for her due to psychological trauma she has experienced.

8. Ms D explains that the physical and mental effects of the birth have had a negative financial impact on her. She says she was unable to work for nearly two years after her child’s birth, and is now only working part-time because her mental health deteriorated. She also says she still cannot sit normally, which affects how she works.

9. Ms D says that the issues with the complaint handling increased her distress. She also believes the incorrect medical notes will harm her future care, as clinicians will rely on inaccurate information.

10. From her complaint, Ms D would like an explanation and acknowledgement of the Trust’s failings, service improvements and a financial remedy.

11. Ms D was undergoing her first pregnancy at 36 weeks when on 6 August 2022 doctors decided to induce the birth due to pre-eclampsia and because they suspected that the baby’s growth had been restricted.

12. Doctors gave Ms D an epidural and induced her birth on 9 August. The staff assessed the effectiveness of the epidural regularly up until approximately an hour before her active labour started and recorded that there was no pain each time.

13. Ms D was in active labour when a doctor had concerns that the baby’s heart rate was dropping and not recovering. Because of this, they recommended an instrumental birth with a ventouse (a vacuum-assisted birth) to safely deliver the baby. The doctor performed an episiotomy, which is a surgical incision made in the perineum, and delivered the baby with a ventouse.

14. After the baby was born, Ms D had a post-partum haemorrhage (bleed after giving birth). After this the doctor then delivered the placenta with controlled cord traction. According to the medical records, the placenta and membranes were delivered complete and the placenta appeared normal.

15. The resident doctor then started suturing (repairing with stitching) the episiotomy and made multiple stitches. The medical records say that the existing epidural was in place and that the doctor gave Ms D lignocaine as local anaesthetic during the procedure. They also say that the bleeding had stopped but there was an ongoing trickle of blood.

16. An examination under anaesthesia, insertion of a Bakri balloon (a medical device to stop uterine bleeding) to manage the bleeding, and repair of any tears then took place..

17. After an overnight stay at the labour ward, Ms D was moved to a postnatal ward where she had a birth debrief with a doctor. She was discharged home on 11 August.

18. Ms D had a second debrief with a doctor the following year to discuss her concerns about the birth.

21. Before we decide if we should investigate a complaint in more detail, we consider a few different factors. One of them is whether we can reach a fair, robust conclusion on what happened.

22. We should consider the evidence provided to us by all parties to the complaint. In some cases, there may not be enough evidence, or the evidence is so equally balanced that even on the balance of probability we cannot come to a view.

Episiotomy without consent

23. Ms D told us that the doctor did not ask for her explicit consent to perform an episiotomy. She said that she felt a sharp pain which she had assumed was part of the labour and only later found out that the resident doctor had performed an episiotomy. She said that although she had agreed to the instrumental delivery, she did not understand that the episiotomy would be part of it.

24. Ms D explained to us that if she would have been told that it would be needed, she would have agreed to it, but the doctor did not say anything about it to her. She said that she did not remember if staff discussed episiotomy with her prior to the birth.

25. In its response, the Trust said that an episiotomy is a normal part of instrumental deliveries used to facilitate the birth and to avoid excessive damage to the perineal tissues. It said that it should have been made explicit and apologised that it had not been. The doctor’s debrief notes said that episiotomy is a usual part of instrumental deliveries and that Ms D was right that a consent should have been obtained or at least the intent undertake it communicated.

26. According to the medical records a midwife had discussed episiotomy with Ms D during an antenatal birth plan meeting. Her birth plan states that she had confirmed that she understands why an episiotomy might be recommended and that although she would prefer to avoid an episiotomy, she would consent to it at the time if it was required. The records made during the active labour say that a verbal consent was gained from her to the instrumental birth. They do not explicitly state whether this included a consent for the episiotomy or say if the resident doctor discussed it with Ms D.

27. We recognise that Ms D experienced this as deeply distressing and that it contributed to her ongoing mental health difficulties following the birth. We have considered whether we would be able to give an independent view on what should have happened and what did happen.

28. The accounts we have received, and the medical records do not enable us to reliably establish what the resident doctor communicated about the episiotomy at the time it was performed. In the absence of contemporaneous evidence, we cannot say whether explicit consent was sought or given during the birth. As we cannot reach a fair and robust conclusion about what happened, a further investigation into this issue would not be beneficial or proportionate. For this reason, we will not take further action on this part of the complaint.

Placenta delivery

29. Ms D said that a doctor forcibly removed her placenta. She recalls the doctor pressing hard on her abdomen, administering an injection intended to aid placental delivery, and then almost immediately pulling on the umbilical cord with force. Ms D believes the placental delivery went wrong because the doctor left insufficient time for the injection to take effect and the bleeding did not stop. She believes that the doctor may have caused damage by removing the placenta in this way.

30. The Trust said that the placenta was removed by controlled cord traction which is part of active management of the third stage labour. It said that according to the NICE Intrapartum guideline, it is a clinically recommended procedure involving traction (pulling) on the cord once signs of separation of the placenta of the wall of the womb happens. It noted that usually there is some fresh bleeding from the cavity of the womb. It also said that the records show that the placenta and membranes were delivered as complete.

31. The doctor’s debrief notes explain that the perceived pulling may have been due to the controlled cord traction which, they say, is a common and known way to deliver the placenta. They also state that the principle is to explain it to the patient and obtain consent and the doctor apologised that neither took place.

32. Our review of the records state that the placenta was delivered with a controlled cord traction. They say that the placenta had a normal appearance and that the membranes were delivered intact.

33. We recognise that Ms D experienced the delivery of the placenta as distressing and painful, and that this contributed to her traumatic experience of the birth. We have considered whether we would be able to independently take a view on what happened. In this situation, there are two differing views on what has happened, and we do not have further independent evidence which would help us to reach a robust conclusion.

34. While Ms D recalls the placenta being removed with excessive force, the contemporaneous records describe the use of a recognised placental delivery technique and do not record complications or signs that would allow us to conclude whether inappropriate force was used.

35. In the absence of objective evidence to support a departure from expected practice, we are unable to reach a fair and robust conclusion about whether the placenta was removed using excessive force. For this reason, we have decided not to investigate this issue further.

Pain relief

36. Ms D says that when the doctor started suturing her episiotomy, they did not check if she was in pain and if her epidural was still effective. She explains that they started the procedure while she was still bleeding and that she was screaming in pain. Only when the midwife intervened, Ms D says, did the doctor administer a local anaesthetic.

37. In its response, the Trust referred to the records and said that Ms D was administered lignocaine, a local anaesthetic, when she had reported that she felt uncomfortable during the suturing. It says that the expectation is that if a patient is in pain, the procedure is stopped and pain relief is given to ensure they remain comfortable, but noted that there is often a sensation of pulling or touch during this type of suturing. The doctor’s debrief notes say that it should not have happened the way Ms D described.

38. The medical records show that an existing epidural was in place and that staff administered lignocaine for pain relief during suturing. The midwife’s notes say that the epidural was last checked at 3.45 pm and was working well, although Ms D had felt some pressure. The time the suturing began is unclear, as it was recorded as 00.00, which appears to be an error given the birth happened at 4.48 pm that day. The midwife’s notes record that at around 5.20 pm Ms D reported ‘mild pain’, and that by 5.25 pm she reported feeling comfortable after lignocaine was given.

39. We recognise that Ms D experienced pain during the repair of the episiotomy and that this was distressing for her. We considered if the available evidence would allow us to establish what happened for us to compare it to what should have happened. The records show that pain relief was in place and that additional local anaesthetic was provided during suturing but do not allow us to establish reliably at which point Ms D first reported the pain, or whether the doctor responded to it with a delay or in an inappropriate way.

40. Without further evidence we are unable to reach a fair and robust conclusion about whether the doctor’s actions during suturing fell short of expected care. Where there is insufficient certainty about what happened to allow a meaningful comparison with expected practice, a further investigation is, regrettably, unlikely to achieve a meaningful outcome. We have therefore decided not to take any further action on this part of the complaint.

Complaint handling and debrief

41. Ms D is concerned that it took the Trust over a year to respond to her complaint and that it added to the distress she was experiencing. She said that she had been promised a further debrief that never took place and received no contact for a long period of time.

42. The Trust acknowledged and apologised for the length of time it had taken to share their complaint investigation with Ms D. Part of which, it said, was because it took time to investigate her complaint thoroughly. It said that that it would be happy to arrange a further debrief for her, additional to the one she had with the consulting doctor in July 2023.

43. We acknowledge that the Trust’s handling of her complaint added to Ms D’s existing distress. Our NHS Complaint Handling Standards say organisations should give complainants a realistic indication of how long an investigation is likely to take. It is likely that the Trust either did not explain this clearly at the outset or did not communicate unexpected delays, since Ms D was unaware of what to expect. We think that the Trust could have communicated its intentions more clearly with her.

44. We cannot say why Ms D believes the Trust did not arrange a further debrief when it should have done so. Although it is possible that the Trust did not communicate clearly what she should do to request one, we do not agree that the Trust was unwilling to arrange an additional debrief to her as it offered to do so in its complaint response.

45. Although we agree that the Trust could have handled some aspects of Ms D’s complaint better, we must take a proportionate approach and focus on issues with the most significant impact on complainants. While we recognise that the complaints process was difficult for Ms D, we think that this issue alone is not significant enough for us to investigate and will therefore not look into it further.

Incorrect records

46. one of the other things we look at before we decide if we should conduct a detailed investigation of a complaint, is whether there is an organisation that is better placed to deal with the concerns. Some complaints can be looked at by us, and also by other organisations. We have considered whether another organisation is better suited to giving an answer to the complaint and whether it can provide the outcome Ms D seeks.

47. Ms D believes that some of the medical records a doctor made during the birth are incorrect. She thinks that in particular the timing of the haemorrhage and the events during the suturing around the pain relief have not been recorded accurately.

48. We consider that the ICO is the organisation best placed to address concerns about inaccurate records. The ICO can look at whether organisations should correct or delete incorrect information, and is therefore more suitable for looking into this part of the complaint. We have signposted Ms D to the ICO and will not be taking this matter forward to a further investigation.

49. We recognise that Ms D wanted clear answers about whether anything went wrong during the birth. While we have not been able to reach a conclusion on the main issues she raised, we hope she is able to move forward successfully from her traumatic birth.

1. We have carefully considered Ms D’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We recognise that Ms D experienced her daughter’s birth as traumatic and are sorry to hear that she has had ongoing mental and physical health difficulties since then.

2. For some of Ms D’s concerns, specifically around consent for the episiotomy, removal of the placenta, and pain relief, we do not consider that we can fairly and robustly reach a meaningful conclusion about what happened during the birth. We also consider that Ms D’s concerns about the accuracy of her medical records are more appropriately dealt with by the Information Commissioner’s Office (ICO). We were sorry to learn that the way the Trust handled Ms D’s complaint contributed to her distress. While we think that the Trust could have handled some aspects of the complaint better, this alone is not significant enough for us to investigate further.

3. For these reasons, we have decided not to investigate in more detail or take any further action on the complaint.