North Bristol NHS Trust

5. Mrs R complains that the Trust did not provide appropriate care when she miscarried in its maternity ward waiting room in September 2022.

6. She says the Trust also failed to investigate her complaint in line with its complaints policy and process.

7. Mrs R says the Trust’s inaction left her life at risk and has forced her to decide not to try and have another child. She says her experience has left her fearful of needing any further treatment and the grief she has for the loss of her baby is tainted by the trauma the Trust put her through.

8. She says the Trust’s response to her complaint has exacerbated her distress and made her feel as though neither she nor her experience matter.

9. Mrs R wants the Trust to recognise its failings and the harm these have caused. She would like it to make a payment to her for this, and for it to implement changes to ensure this does not happen to someone else.

10. Mrs R asks that the Trust also takes steps to improve its complaints process.

11. Mrs R was just under 12 weeks pregnant with her second child when she attended a maternity ward within the Trust in September 2022. She was experiencing heavy bleeding and was feeling unwell. Sadly, Mrs R miscarried and needed to stay overnight.

12. She complained to the Trust later that month. Mrs R discussed the issues with the Trust on several occasions. The Trust provided its final response in June 2023. This acknowledged the failings it demonstrated in providing Mrs R’s care when she attended and set out the actions it had undertaken to improve this for future patients. The Trust also apologised for the experience Mrs R had at an already very difficult and upsetting time.

Clinical concerns

16. When we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so, we cannot link the events complained about with the extent of the negative impact Mrs R has claimed. We also think the Trust has already done enough to put right the impact of these events within the scope of what we think is appropriate.

17. Mrs R complains that the Trust did not provide appropriate care when she miscarried in its maternity ward waiting room in September 2022. Mrs R says the Trust’s inaction left her life at risk and has forced her to decide not to try and have another child. She says her experience has left her fearful of needing any further treatment and the grief she has for the loss of her baby is tainted by the trauma the Trust put her through.

18. The Trust has acknowledged that Mrs R did not receive the level of care she should have when she arrived at the ward. The Trust said that it aims to see patients within 15 minutes, but she was not seen until two and a half hours after she arrived. Because of the apparent agreement in this regard, we have focused our consideration on the impact of the failings in the Trust’s actions.

19. We accept that the situation was very distressing and are sorry Mrs R experienced this. Mrs R was actively miscarrying in a waiting room where there were other people present. Not only would this have been both worrying and upsetting for her we are mindful that she reports feeling unwell at this time.

20. Clinical observations were completed when Mrs R was initially seen on the gynaecology unit (after her long wait) at 17:10. Her blood pressure, heart rate and temperature were normal, and her NEWS was 0. NEWS refers to the National Early Warning Score which is used throughout the NHS to assess the degree of illness of a patient. It can then be used to identify any deterioration in a patient’s condition. A score of 0 reflects no change to the standard expected baseline. It means the patient does not need to be monitored any more frequently than once every 12 hours.

21. Mrs R also had bloods taken from her for testing. Her haemoglobin (a protein located within red blood cells) was around 12g/dL which is within the normal range. Haemoglobin levels often decrease and become low with substantial blood loss.

22. Our adviser noted that her heartbeat was on the low side, but not enough to make it a major concern that needed monitoring.

23. A doctor examined Mrs R at 17:15 and they noted she was feeling unwell. She was clammy, lightheaded and had vomited. On examination she was found to have placental tissue (part of the placenta) lodged in her cervix. Our adviser explained that it is likely this caused ‘cervical shock’ which is a vasovagal attack (a reaction within the body to some kind of stimuli, which causes the patient’s heart rate and blood pressure to drop, often leading to fainting) secondary to cervical dilatation by the tissue (the widening of the cervix to allow tissue to pass through). The possibility of Mrs R experiencing cervical shock is made more likely by the Trust’s records reflecting that she felt better once the tissue was removed.

24. Given the length of time Mrs R had been waiting to be seen by a doctor, we considered what might have occurred had she not been seen when she was. Our adviser felt that, had the tissue not been removed manually, it was likely that Mrs R would have passed this tissue naturally at some point. She would have continued to feel unwell until that time and may have fainted.

25. We have also considered the fact Mrs R was admitted to the ward overnight to see what this tells us about the severity of her condition. Our advisor explained that her admission was precautionary and in response to her feeling unwell during her miscarriage. Symptoms like Mrs R exhibited can sometimes be linked to an ectopic pregnancy (where the embryo attaches itself outside the womb, usually in a fallopian tube), which meant that it was a sensible precaution for her to be observed overnight. We are satisfied that the Trust admitted Mrs R to enable it to rule out the possibility of her pregnancy being ectopic rather than this being because of the miscarriage itself.

26. It is accepted that Mrs R was left unattended for some time while she was feeling increasingly unwell. We have no doubt that this would have been both worrying and distressing. Based on what we have found, we have not seen evidence to show Mrs R’s life was in danger, given her normal observations and haemoglobin levels. The delay in her being seen meant that it is possible that she may have fainted from the cervical shock had she waited significantly longer. We are satisfied that her life was not at risk at any point.

27. Mrs R says the delay she experienced made her decide to not try to have another child. We recognise that this is an incredibly difficult decision to make and that it is very emotive. We feel there are too many variables involved in reaching such a decision for us to be able to say on the balance of probabilities that this decision was solely because of the delay she experienced.

28. Mrs R wants the Trust to recognise its failings and the harm these have caused. She would like it to make a payment to her for this, and for it to implement changes to ensure this does not happen to someone else.

29. The Trust has already recognised its failings, apologised and taken steps to prevent a situation like this from happening again. It has introduced a new triage system and improved signage to communicate waiting times and the suggestion of raising concerns if this is exceeded. There have been staffing changes alongside training and reminders for staff to be more aware of what is happening with patients in the waiting room. A designated staff member is also now allocated to each patient arriving and bring triaged.

30. We think these actions address the main point of this complaint which is Mrs R not being assessed and examined with the appropriate urgency when she presented with symptoms of active miscarriage. We do not think there is anything additional for us to recommend the Trust does that it has not already done.

31. With regard to Mrs R’s request for financial compensation, this is something we have explored with her. When we initially considered her first complaint (which we closed to allow her to pursue her concerns with the NMC) this was not something she had asked for. When she came back to us to open this case, she told us she was seeking a payment of £12,450, representing the top end of level five of our Severity of Injustice scale. She explained that she had asked for this as she had had more time to consider the impact of the Trust’s actions and because she understood the changes we had made in our complaint form to specifically ask about this suggested we thought this was appropriate for her case.

32. Level five cases usually occur where the person affected has had a marked and damaging effect on their ability to live a relatively normal life and where recovery is likely to take a significant amount of time. While we can see how Mrs R feels her case fits into this category, we do not think there is sufficient evidence to demonstrate this is the case. We are mindful that our focus must only be on the delay Mrs R experienced. We have outlined that there was no significant impact to Mrs R’s physical health caused by this. There is no suggestion that being seen much quicker would have made any difference to the sad outcome. It is difficult to separate the effect of the wait alone from the effect of the miscarriage itself which was, undoubtedly, heartbreaking.

33. Having considered this at length, and in view of the advice we received about the impact to Mrs R’s physical health, we believe that any payment we would potentially recommend the Trust make would be within the level three category. Level three cases would have a moderate impact on the person affected (for example, in terms of distress, worry or inconvenience). For a case to be level three, that impact would usually have been experienced over a significant period. Alternatively, as we think applies here, a case may also be level three if the impact on the person affected was significant but was only sustained for a short period of time.

34. We approached the Trust with our thinking and are pleased it was receptive to our findings. Having discussed the matter with it at length, it has told us it would be willing to provide Mrs R with a payment of £900. This falls into the middle of the level three range and is a sum we are confident is appropriate. The Trust has confirmed it will make this payment to Mrs R accordingly.

35. It is therefore our view that the Trust has sufficiently recognised the impact we have identified as occurring as a result of the delay. As a result, we will not consider this aspect of Mrs R’s complaint further.

Complaint handling

36. Mrs R complains that the Trust failed to investigate her complaint in line with its complaints policy and process. She says it did not do this with openness and candour, did not adequately address her concerns and provided responses which lacked transparency and accountability.

37. The Trust’s policy should be considered in conjunction with our ‘NHS Complaint Standards: Summary of expectations’ (the Standards). These say that the Trust should see complaints as an opportunity to develop and improve and set clear expectations to ‘embed an open, non-defensive approach’ to learning from complaints.

38. Part of Mrs R’s dissatisfaction with the Trust’s response to her complaint is that she feels it has not been open with her, or with its approach to considering and addressing her concerns. It seems this is related to the Trust telling her it operates a ‘no blame’ culture.

39. This does not mean that its staff are able to act without fear of accountability or consequence. It shows the Trust is acting in line with the Standards. It allows staff to be honest and open about what happened without feeling as though the focus is on blame or punishment for what might have gone wrong. Instead, it focuses on staff acknowledging where mistakes have been made and learning from this to ensure the situation does not happen again.

40. We understand that Mrs R wants to know why she was left for so long in the waiting room, which members of staff were responsible for this and what repercussions have occurred because of this. We acknowledge that her not having this information is frustrating and upsetting. That said, the Trust has not demonstrated a failing in not giving this to her.

41. It is clear from its responses that it has discussed Mrs R’s complaint with the relevant staff members. This meant a delay in responding to the complaint to allow it to do so. The Trust explained this to Mrs R. The Trust has also explained that it has used Mrs R’s concerns as an opportunity to learn and improve its service. Any action it might have taken to identify individual staff members and any consequences of it doing so would not be appropriate to share with Mrs R as this would constitute a personnel matter.

42. Mrs R made her complaint to the Trust in September 2022. It provided its final response in June 2023. She complains that this was not done adequately or with sufficient transparency and accountability.

43. The Standards say that organisations should set out what happened and whether mistakes were made. Responses should set out how the organisation is accountable and identify suitable ways to put things right.

44. We can see that, following Mrs R’s initial complaint the Trust contacted her by phone to discuss the issues raised. After this, she asked for the Trust to provide a written response to her concerns. She sent in additional information for its consideration as well.

45. The Trust responded in January 2023, although Mrs R seems not to have received this until it was resent in March. This was a lengthy reply which built on the conversations Mrs R had already had with staff members about her complaint. We think this conforms to the Standards as it was clear where the Trust made mistakes and what it had done, or was doing, to put this right. The letter also contained apologies for the experience Mrs R had.

46. Mrs R was unhappy with the response as she felt it did not respond to all her questions fully. She told the Trust this in March when she received the January response. The Trust considered this and provided its final response in June.

47. We feel the Trust’s second response was also in line with the Standards. It was transparent in its findings and was clear about what steps it had taken to prevent anyone else experiencing the same problems. While we acknowledge that Mrs R still does not have answers to some specific questions, we are satisfied that she has received an appropriate response. This links back to the earlier issue of her wanting to understand why she had the experience she did, and the lack of ability to provide this information.

48. The Standards say that staff should discuss timescales with those involved in the complaint and provide regular updates throughout. We can see that the Trust provided several timescales for response, most of which were not met. We appreciate the frustration this will have caused Mrs R. We are, however, mindful that the Standards require organisations to provide honest and open answers as quickly as possible, depending on the complexity of the complaint. It is clear from the information provided that there were many parts to Mrs R’s complaint and involved numerous different staff members. The Standards also say that all staff members involved in a complaint should be given the opportunity to give their views and respond to emerging information.

49. Despite the delays and missed timescales, we can see that the Trust kept Mrs R updated. While we understand it was not ideal, and likely added to her frustration, the Trust was open about why delays had occurred and why it had not issued correspondence when it had indicated it would. The Trust has therefore acted in line with the Standards in this regard.

50. In addition, we can see that the Trust has apologised where it has missed deadlines or not provided Mrs R with information she asked for. This is in line with the Standards.

51. We recognise that waiting for the Trust to respond to her complaint has added to Mrs R’s existing distress about the situation. We have no reason to doubt that she has been upset by this and remains disappointed with the replies she has received. Based on what we have seen, we find no significant failings in its complaint handling and so will not consider this aspect of the complaint further.

52. We reiterate our condolences for the loss Mrs R, her husband and her son have experienced. We wish them well for the future.

1. We have carefully considered Mrs R’s complaint about North Bristol NHS Trust (the Trust). We are sorry to hear about the difficult experience she had, and we would like to express our sincere condolences for her loss.

2. We have not been able to link the Trust’s failings to the extent of the impact Mrs R has described. This does not mean that we doubt what she says, we are simply unable to say with any degree of certainty, that the delay in being seen was the cause of the difficult decision she has made, or that this meant her life was at risk.

3. That said, we do think that Mrs R has experienced distress as a result of the Trust’s failing. Having discussed this with it, the Trust has confirmed it will make a payment of £900 to Mrs R to recognise this. As we think this is an appropriate sum, we do not think it needs to take any further action.

4. Finally, while we note Mrs R’s dissatisfaction with the Trust’s complaint handling, we have not identified any significant failings within this.