University Hospitals Birmingham NHS Foundation Trust

6. Mrs I complains the Trust did not monitor her anti-D levels when it noted 28 weeks into her second pregnancy in 2022 that she had produced enough of her own anti-D. She says if the Trust had done this, it should have prompted the Trust to do more to ensure her second pregnancy went smoothly.

7. Mrs I also complains the Trust did not explain to her until she was mid-way through her third pregnancy in 2023 about what happened with the other pregnancies she had. She says if the Trust had done this, she and Mr H would have been more prepared for what was going to happen.

8. As a result of these events, Mrs I experienced trauma, stress and anxiety. Mrs I says she had been told that any future pregnancies would cause more issues each time, and a baby would be more premature that the one born after the third pregnancy. She says this has taken the option away of having any more children which is devastating for her and her family.

9. She is seeking an acknowledgement of failings and an apology for the impact of these, service improvements, and a financial remedy.

10. This is a brief background to place the key events to this complaint in context. It does not provide a full account of everything that happened.

11. Mrs I’s blood group is Rh D Negative. Rh D negative blood means a person’s blood cells lack the Rhesus D antigen.

12. In early 2022, Mrs I became pregnant. In April, Mrs I underwent a blood test to determine the unborn baby’s D blood group. The results reported the baby’s blood group was predicted to be Rh D positive.

13. In mid-October, Mrs I gave birth to baby R. The Trust kept R in hospital for around ten days due to the extra care he needed.

14. Mrs I became pregnant again in August 2023. In February 2024, Mrs I’s baby underwent an in-utero transfusion.

15. Mrs I’s baby B was born at 28 weeks old in late February, via an emergency caesarean section. The Trust kept her in hospital for approximately five days, however it kept baby B in hospital for approximately seven weeks. The baby underwent numerous treatments.

2022 pregnancy

19. Mrs I complains the Trust did not monitor her anti-D levels when, at 28 weeks into her second pregnancy in 2022, it noted that she had produced enough of her own anti-D.

20. The Trust explained the results of Mrs I’s blood test at her 28-week appointment showed anti-D antibodies, and the level was low at 0.8IU (international unit). The Trust said the recommendation was to repeat the antibody test every two weeks until birth, however this did not happen.

21. Before outlining the relevant guidance, we will provide some context on anti-D immunoglobulin. Anti-D immunoglobulin is made from the plasma within the blood. This medicine is provided to Rh D pregnant people to prevent the creation of antibodies against Rh D-positive blood cells. Without this, antibodies may cross into the baby’s bloodstream and attack the baby’s red blood cells. This is called haemolytic disease of the newborn (HFDN).

22. Section 6.8 of the RCOG guidance says anti-D levels should be measured every two weeks, from 28 weeks, until delivery. This is to monitor the level of antibodies and to identify any additional antibodies that may have developed.

23. In the medical records, there is a note from the midwife approximately a week after Mrs I’s 28-week appointment. The note indicates the midwife reviewed the blood results and the low levels of anti-D antibodies. It carries on saying the midwife discussed the results with the blood bank, and notes ‘prophylactic anti-D not required. Patient informed of results and that [the] foetal screening will be in contact if needs further antibody bloods in pregnancy’.

24. Our obstetric adviser notes there is no record of a discussion with the antenatal screening team, or of any plan to repeat the antibody blood test. This is despite the report issued from the laboratory from the 28-week blood test which says ‘guidelines recommend repeat testing every two weeks until delivery’.

25. The next time the Trust measured Mrs I’s anti-D levels was three days before she gave birth in October.

26. Based on the evidence, the Trust’s actions are not in line with the RCOG guidance. This is because it did not monitor Mrs I’s anti-D levels every two weeks, from 28 weeks, until she gave birth.

27. We recognise how worrying it was for Mrs I and Mr H when they found out the Trust had failed to do the blood tests it should have done. There are failings here. We will consider the impact of this later in the report.

2024 pregnancy

28. Mrs I complains the Trust did not explain to her until she was mid-way through her third pregnancy about what happened with the other pregnancies she had.

29. The Trust explained there is a 50 percent chance of having a baby with the mother’s blood group or the father’s blood group. It further explained that it undertook the test for FMH (foetalmaternal haemorrhage – transfer of foetal blood into the mother’s blood) following the second pregnancy. It said the results did not indicate Mrs I required an anti-D injection at the time.

30. Section 4.1 of the RCOG guidance says women with clinically significant red cell antibodies should be given information regarding the possible implications, both for the mother and the baby, to the pregnancy. This will depend on the type of antibody present. The RCOG guidance says counselling should be by a clinician with knowledge and expertise of this condition, and in most cases this will be a foetal medicine specialist.

31. We could not evidence in the medical records that the Trust explained the relevance of Mrs I being Rh D negative. This does not appear to be line with the RCOG guidance.

32. More importantly, our obstetric adviser reiterated that the Trust did not monitor Mrs I’s antibodies every two weeks after 28 weeks in her second pregnancy. As such, a referral to, and counselling by a foetal medicine specialist did not occur. This is also not in line with the RCOG guidance.

33. We acknowledge that Mrs I feels she and Mr H could have been more prepared if information had been shared with them. We recognise this has contributed to the stress they experienced. There are failings here. We will now consider the impact of this.

Impact

34. Mrs I says if the Trust had monitored anti-D levels in her 2022 pregnancy, it should have prompted the Trust to do more to ensure her second pregnancy went smoothly. She also says if the Trust had explained to her what happened with her other pregnancies, she and her partner would have been more prepared for what was going to happen.

35. As a result of these events, Mrs I says she experienced trauma, stress and anxiety. Mrs I says she has been told that any future pregnancies would cause more issues each time, and a baby would be more premature than the one born after the third pregnancy. She says this has taken the option away of having any more children which is devastating for her and her family.

36. We have found the Trust failed to act in line with the RCOG guidance. It failed to monitor Mrs I’s anti-D levels every two weeks between 28 weeks and when she gave birth. It also failed to inform Mrs I of the relevance of being Rh D negative, or to provide counselling by a foetal medicine specialist.

37. The RCOG guidance says an anti-D level greater than four IU/ml but 15 IU/ml or lower is associated with a moderate risk of HDFN. An anti-D level greater than 15IU/ml can cause severe HFDN. Referral for a foetal medicine opinion should be made once anti-D levels are greater than 4 IU/ml.

38. Mrs I’s levels at her 28-week appointment were 0.8 IU/ml. When the Trust re-took Mrs I’s anti-D antibody levels three days before delivery, her levels had risen to 37.5 IU/ml. Therefore, Mrs I’s anti-D antibody levels rose more than 4 IU/ml at some stage between 28 weeks and 39 weeks pregnant. We cannot say at what point this occurred, due to the absence of any tests.

39. If the Trust had monitored Mrs I’s anti-D antibody levels, our obstetric adviser says the Trust would have detected the rise in levels and prompted a referral to foetal medicine. This, in turn, would have led to scanning to look for signs of foetal anaemia. Our obstetric adviser says if there had been signs of foetal anaemia, this would have led to consideration of an in-utero transfusion, and/or earlier delivery.

40. When R was born following Mrs I’s second pregnancy, the Trust noted him to be jaundiced, and it transferred him to the neonatal unit. The Trust treated R with intensive phototherapy, intravenous immunoglobulin and a blood transfusion. R was in hospital for approximately ten days before the Trust discharged him home. The Trust monitored R as an outpatient and prescribed him oral folic acid supplements.

41. We asked our neonatal adviser whether, on the balance of probabilities, any of the treatment R received could have been avoided, or reduced, if the Trust monitored Mrs I’s anti-D levels in her second pregnancy.

42. The RCOG guidance explains the timing of delivery for women with red cell antibodies that can cause foetal anaemia depends on several factors. In general, for red cell antibodies that could cause foetal anaemia, but which have been stable throughout pregnancy, delivery should take place between 37 and 38 weeks of gestation.

43. Our neonatal adviser explained that if R had been born one week earlier (R was born at 39 weeks and three days), it is possible the severity of the HDFN may have been reduced. On the balance of probabilities, however, our neonatal adviser says the treatments R received would not have been significantly different. Nor can they say he would have had a shorter stay in hospital.

44. Although we cannot link any clinical impact to the Trust’s actions, this does not undermine the emotional and psychological impact caused to Mrs I. We cannot imagine the stress and worry both Mrs I and Mr H went through whilst their baby was in hospital. Especially with baby B from their third pregnancy, who was born prematurely and the Trust kept in hospital for a significant amount of time.

45. We recognise being pregnant can be a source of worry, even more so when there have been previous complications. The RCOG guidance says someone with a history of pregnancy or infant related HDFN should be referred for early assessment to a foetal medicine specialist in all further pregnancies. The risk of recurrence of HFDN depends on several factors.

46. We understand Mrs I and Mr H feel the option of having any future children is limited, due to the risks to the baby. We think if the Trust had counselled Mrs I about what was happening in her second pregnancy (and for future pregnancies), any worries or concerns could have been minimised. We also recognise that the lack of understanding what was happening, until the third pregnancy, would have also been distressing and worrying. This also could have been reduced if they had known what was likely to happen.

47. We do not think the Trust’s actions limits the decision of Mrs I and Mr H of whether to have more children or not. We do acknowledge, however, that Mrs I and Mr H may have felt differently if they had been more aware prior to Mrs I becoming pregnant.

48. The Complaint Standards say organisations should explain why things went wrong and identify suitable ways to put things right for people.

49. The Trust apologised for the missed opportunity to check Mrs I’s 28-week blood test results for her 2022 pregnancy, and to repeat antibody tests. This would have identified antibody levels and given the Trust the opportunity to explain the implications if the levels were increasing prior to labour. The Trust explained that it wrongly thought Mrs I’s anti-D blood levels were also being taken when she was having blood taken in the rheumatology clinic.

50. Overall, the Trust apologised for the poor experience Mrs I received from the Trust. However, we do not think this addresses all the failings we have found, or fully recognises the impact of these. We will be asking the Trust to take further action to put things right for Mrs I. We have set out details of this in the next section of this report.

51. The Trust says it has advised all doctors in antenatal clinics to routinely check the 28-week bloods for all women as a failsafe. Especially if women come to the antenatal clinic after 28 weeks. It also says reminders have been sent to all staff about the need to ensure two-weekly blood tests for patients if needed (anti-D levels), as well as sharing wider feedback to prevent similar events from happening again.

52. We think the actions already taken by the Trust here are in line with the Complaint Standards, and it has made a good start on putting things right. So we will not be asking it to make further service improvements. We have outlined our recommendation below.

1. We were sorry to hear of the events Mr and Mrs I complain about, and the impact these events had on them. We understand this was a difficult time for them both.

2. We have found failings in how the Trust monitored Mrs I’s anti-D levels, from 28 weeks in her second pregnancy, until she gave birth. We also found failings in how the Trust did not explain to Mrs I the possible implications of her Rh D negative blood type and what this means in pregnancy. This did not happen until her third pregnancy.

3. We recognise that the lack of understand of what was happening, until the third pregnancy, was distressing and worrying. This could have been reduced if they had known what was likely to happen. We also understand the emotional and psychological impact this had to Mrs I and Mr H, especially when the Trust kept their babies in hospital for treatment.

4. We are unable to say the treatment R, Mrs I and Mr H’s son, had would have been significantly different if these failings had not occurred. Nor can we say he would have had a shorter stay in hospital. Similarly, we cannot say the Trust’s actions has affected Mrs I’s options about whether to have future children. This is because we think she is likely to have issues due to her blood type.

5. We recommend the Trust pay Mrs I £700 in recognition of the impact of the failings we have found.