Dorset Healthcare University NHS Foundation Trust

5. Mrs L complains about the following aspects of the care and treatment provided by the Trust. Mrs L says:

• on 13 July 2024 Dr A told her that her pregnancy was viable and shouted at her when she questioned it • the Trust failed to provide a promised letter outlining the actions taken in relation to Dr A’s behaviour • she was dissatisfied with the internal complaint process, describing it as a “cover-up”.

6. As a result of the above issues Mrs L says:

• she felt fearful for her health due to the risks of ectopic pregnancy (this is when a pregnancy occurs in an unsafe part of the body) • she has an ongoing fear of returning to the same hospital and encountering the same staff • the stress of the misdiagnosis led to a diagnosis of fibromyalgia (An illness causing widespread pain and fatigue) which significantly affects daily life • the stress of this caused a mental health breakdown as well as ongoing stress and anxiety requiring multiple medications and ongoing management • her mental health issues have strained family relationships with her sister deciding that Mrs [name redacted] should not continue seeing her niece due to concerns about her mental health • the lack follow up and robust complaints procedure made her feel her issues were not taken seriously.

7. By bringing this complaint to us Mrs L wants:

• a financial remedy for the distress caused • service improvements to ensure the safeguarding of pregnant women beyond the communication training outlined in the complaint response • a full independent investigation into the events

8. Mrs L told us she visited the Trust on 11 July 2024 for tests which regrettably revealed an ectopic pregnancy in her left fallopian tube. An ectopic pregnancy cannot survive.

9. Despite being taken for surgery, once the pregnancy was explored the Trust decided to continue monitoring the pregnancy as it was expected to end naturally. This would preserve her fallopian tube, the location of the pregnancy.

10. The Trust booked a followup appointment to carry out further blood tests and an ultrasound, a scan used to monitor pregnancy. It planned to prescribe Mrs L with Methotrexate, a drug used to bring on a miscarriage should the pregnancy not end naturally.

11. Mrs L says at her follow up appointment on 13 July Dr A explained the pregnancy was viable. This means it could develop and survive. Mrs L says when she questioned this, Dr A shouted at her quoting the significant experience he held in this speciality.

12. Dr A prescribed Mrs L progesterone, a hormone that supports early pregnancy by reducing the risk of miscarriage. Later that day another doctor caring for Mrs L confirmed the pregnancy was ectopic.

13. Mrs L’s left fallopian tube was surgically removed on 16 July 2024.

14. Mrs L raised her complaint informally with the Trust’s Patient Experience Team on 16 July 2024. In this email, Mrs L was able to provide accurate details regarding her treatment and test results which is corroborated by the medical records.

15. Mrs L also states Dr A told her the pregnancy was viable and she was shouted at when she questioned this view in light of the earlier ectopic pregnancy diagnosis.

16. Mrs L raised a formal complaint with the Trust in October 2024. Mrs L asked why Dr A said the pregnancy was viable and told of the impact this communication had on her.

17. The Trust responded on 16 January 2025 acknowledging Dr A may have caused confusion in his communication, but it denies he confirmed the pregnancy was viable.

18. It could see Dr A had interpreted from the records that an ectopic pregnancy was not seen during the surgery on 11 July 2024. The Trust apologised for this inaccuracy as it could see the notes from 11 July did confirm the ectopic pregnancy was seen and confirmed.

19. The Trust accepted Dr A confirmed further tests were required to determine whether the pregnancy was ectopic. In its formal response, the Trust acknowledged that by this point it was already established the pregnancy was ectopic and as a consequence, Dr A provided information that led to Mrs L’s confusion and distress.

20. Mrs L continued treatment with the Trust to support her in her attempt to have a baby and attended a consultation in October 2024.

21. Whilst we have not been a party to the consultation that took place in October 2024, we understand Mrs L asked that she receive an update to the steps taken following her raising her complaint.

22. Mrs L raised the complaint with our service in May 2025.

23. Mrs L emailed the Trust in June 2025 explaining she was yet to receive an update from a consultant as promised in October 2024. Mrs L explains she was told that she would receive an update following a clinical review meeting that was due to take place regarding her treatment.

26. We understand Mrs L was distressed that on 13 July 2024, Dr A told her the pregnancy was viable and shouted at her and her husband when they questioned this. We recognise the seriousness of these concerns and the impact they had on her at an already very difficult time.

27. Before deciding whether to carry out a detailed investigation, we consider whether there are indications of service failings or maladministration that the organisation has not already addressed.

28. Having reviewed the information, we are satisfied the Trust caused confusion that has led Mrs L to believe that her pregnancy was viable but believe that it acted reasonably in its follow up actions and in how it handled the complaint. We have explained our reasons for this below.

Communication with Dr A

29. Mrs L says she was distressed that on 13 July Dr A who told her the pregnancy was viable contradicting an earlier ectopic diagnosis. She says he also shouted at her and her husband when they questioned the diagnosis.

Information about pregnancy

30. We recognise the circumstances surrounding Mrs L’s complaint were traumatic. Losing a baby is an emotionally devastating experience, and concerns about how Dr A communicated added to her distress. It is clear this contributed to her anxiety, and we are sorry for the additional upset this caused.

31. We are grateful for the level of detail Mrs L provided. She was able to recall her treatment clearly and supplied written notes made shortly after the appointments, which helped us understand her experience.

32. All parties agree Mrs L was told she had an ectopic pregnancy at her appointment on 11 July.

33. Mrs L states that during her appointment on 13 July Dr A told her the pregnancy was viable, contradicting the earlier diagnosis.

34. The medical notes confirm the ectopic pregnancy had been identified in earlier appointments. They do not record Mrs L being told the pregnancy was viable on 13 July, but they do state the Trust told her an ectopic pregnancy was not seen during her surgery. This was incorrect.

35. The medical records, and Mrs L’s own account, confirm progesterone was prescribed. This is a drug used to support the healthy development of a viable pregnancy. The Trust explained this was given to offer Mrs L a sense of support.

36. In its complaint response, the Trust acknowledged Dr A told Mrs L she required further tests to determine the location of the pregnancy. It accepted this was incorrect, given the ectopic pregnancy had already been confirmed, and that this contributed to Mrs L’s confusion and distress.

37. When Mrs L attended her appointment on 13 July, Dr A was required to follow GMC guidance.

38. GMC guidance states that doctors must provide patients with accurate information about their condition and treatment options. This includes ensuring explanations reflect the medical findings and are communicated in a way the patient can understand.

39. Doctors must also work effectively with colleagues and ensure continuity and consistency of care. This requires them to take account of information recorded by other clinicians, to understand the patient’s existing diagnosis, and to ensure that any advice given is in line with the medical notes.

40. The GMC guidance further asks doctors to seek advice when needed. Where there is uncertainty about a diagnosis or the interpretation of findings, doctors should review the available information carefully or seek clarification before offering clinical statements.

41. GMC guidance states that doctors must ensure patient records are clear, accurate, written at the time of events and legible. These records should be used to inform clinical decisions and the information provided to patients.

42. The standards are clear and mean that Dr A should have ensured he understood the clinical records from 11 July, verified any areas of uncertainty, and provided Mrs L with information that was accurate, consistent with the established diagnosis.

43. Following our review of the available evidence, there were several areas where the care and communication Mrs L received on 13 July did not align with GMC guidance.

44. The records show the ectopic pregnancy had already been identified and confirmed on 11 July. Despite this, Mrs L was told further tests were needed to determine the location of the pregnancy.

45. This was contradicting to the previous established diagnosis and did not reflect the requirement for doctors to provide accurate information as per GMC guidance.

46. Dr A also informed Mrs L that an ectopic pregnancy had not been seen during the surgery, which the Trust later accepted was incorrect. This suggests the clinical records were not accurately interpreted, which is not in line with the expectations around continuity of care.

47. The decision to restart progesterone treatment, further indicates that the confirmed diagnosis may not have been fully understood.

48. It is our view it is likely that Dr A had not verified the clinical information available before making treatment decisions, as required under the GMC guidance.

49. NICE guidance does not recommend the use of progesterone in the management of ectopic pregnancy.

50. NICE guidance provides detailed instructions on the use of progesterone for women with a suspected miscarriage in an intrauterine pregnancy (pregnancy that occurs in the womb), which Mrs L’s pregnancy was not. Progesterone has a recognised role in supporting intrauterine pregnancies, but there is no guidance supporting its use in ectopic pregnancies.

51. In its response, the Trust accepted that Dr A’s communication may have caused confusion. While it denied that he confirmed the pregnancy was viable, it acknowledged he had incorrectly interpreted the 11 July records as showing no ectopic pregnancy. The Trust apologised for this error, and confirmed the records of the ectopic pregnancy were accurate.

52. Considering the information provided and the prescribed progesterone, whilst we are unable to determine exactly what was said in the appointment on 13 July, it is our view that it was reasonable for Mrs L to believe her pregnancy was viable based on the outcome.

53. The surgery results clearly showed Mrs L had an ectopic pregnancy, this means Dr A did not communicate in line with GMC guidance, there is an indication of a failing.

54. We recognise the importance of early diagnosis and appropriate treatment of ectopic pregnancies. As it enlarges within a part of the body not designed for this, the pregnancy will inevitably start to cause bleeding. If within the fallopian tube, it will often cause rupture which can lead to internal bleeding.

55. We understand from the medical records that Mrs L has previously had failed pregnancies. From our discussions we noted that Mrs L was knowledgeable on the subject and understood the risks of ectopic pregnancies. During our discussion Mrs L confirmed she felt fearful for her health due to the risks of ectopic pregnancy.

56. We accept that this uncertainty because of the conflicting information may have led to Mrs L’s anxieties over her health as a result of the risks of an ectopic pregnancy.

57. Given her knowledge of ectopic pregnancy and her previous experiences of pregnancy loss, we consider it likely that the conflicting information she received on 13 July increased her anxiety at an already distressing time.

58. We also recognise the wider impacts Mrs L described. She told us the stress of the situation contributed to a diagnosis of fibromyalgia (a condition causing widespread pain and fatigue), ongoing mental health difficulties, and strain on her family relationships.

59. We do not underestimate the seriousness of these conditions or the effect they have had on her daily life.

60. We understand how this has affected Mrs L but have also noted that the incorrect information she received was corrected within approximately 24 hours. While this does not diminish the distress she experienced, the available evidence does not allow us to conclude that the failings were the cause of the longer term conditions she has described.

61. We are unable to establish a direct link between the failings we have identified and the development of Mrs L’s fibromyalgia or her longer term mental health deterioration. We cannot say this event was so distressing that it had a profound and lasting effect.

62. We are satisfied, however, that the conflicting information given on 13 July caused Mrs L avoidable distress at a time when she was already vulnerable and fearful for her health.

63. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

64. The Trust’s complaint response acknowledged the failings, accepted the information Dr A provided was incorrect, and recognised this contributed to Mrs L’s confusion and distress.

65. Given the matter was clarified within 24 hours, we are satisfied this was a proportionate response for the Trust’s actions and in keeping with what we would expect to see. For this reason we do not propose to look at this part of the complaint any further.

Dr A shouted at her

66. Mrs L says that when she questioned the viability of her pregnancy, Dr A shouted at her and claimed that he was an experienced Doctor in that field.

67. From a review of the medical records there are no entries that indicate that there were any raised voices or that there were any disagreements over the diagnosis.

68. During their investigation the Trust asked for Dr A’s recollection of the appointment, and while he did recall telling Mrs L that he had done his job for many years, there was no reference to any raised voices or arguments.

69. The GMC guidelines set clear expectations for how doctors should communicate with patients. Doctors must listen to patients, respond to their questions, and communicate in a way that is respectful, clear and supportive.

70. The guidance applies during all communication but is particularly relevant when a patient seeks clarification or expresses concern about the information they have been given.

71. Where accounts differ, we make findings on the balance of probabilities, taking into account the reliability of the available evidence.

72. We cannot reach a conclusion on whether Dr A shouted at Mrs L given the limited evidence. This means we cannot go as far to say they did not act in line with GMC guidance.

73. However, in this case, the Trust has confirmed that Dr A has undertaken reflective practice regarding the concerns raised about his communication.

74. Reflective practice guidance says when disagreements of this nature arise, NHS staff are expected to reflect on what happened and consider how their communication may have contributed to the situation. Reflection is an important part of professional practice and supports learning.

75. It is particularly important where a patient feels their concerns were not fully heard or where the interaction has caused distress, as this helps NHS staff understand the impact of their approach and identify how they might communicate more effectively in future.

76. Although we cannot independently reach a view Dr A shouted, this is what we would expect to see the Trust do to resolve an issue of this nature. We hope this offer Mrs L reassurances the Trust has taken her complaints seriously.

Letter outlining the actions taken

77. Mrs L emailed the Trust in June 2025 explaining she was yet to receive an update from the Trust as promised in October 2024. The updates related to a clinical review meeting that was due to take place regarding her treatment.

78. The records show Mrs L saw a doctor in October 2024 where her treatment was discussed in line with what Mrs L has stated.

79. Records provided by the Trust include a letter issued to Mrs L in November 2024, where a departmental meeting was referenced. In this letter the doctor confirmed that Mrs L’s experience was discussed at a departmental meeting as the Trust felt there were many learnings from her experience that should be shared.

80. The Trust’s complaint response also highlights actions the Trust has taken as a result of the complaint. This is dated January 2025.

81. When discussing this with Mrs L she felt that these letters did not go in to the level of detail that she had expected.

82. The NHS constitution sets out that patients have the right to receive information about their care clearly.

83. When a patient is told that their care will be reviewed or discussed at a departmental or clinical meeting, the Trust should provide an update that confirms the review has taken place and outlines any learning or actions arising from it.

84. In this case, the Trust provided Mrs L with information about her care through the follow up letter in November 2024, and the complaint response in January 2025.

85. We are satisfied this meet the requirements of the NHS constitution to provide clear information. We appreciate and understand why Mrs L wanted to see more detail but we cannot conclude that the Trust’s actions fell so far short of expectations that we would consider it a failing.

86. For this reason we do not propose to consider this part of the complaint further.

Dissatisfaction with the internal complaint process

87. When Mrs L referred her complaint to us she told us she was dissatisfied with how the Trust handled the investigation. She felt it lacked transparency and believed the response letter attempted to minimise Dr A’s errors.

88. She is unhappy that the Trust’s response just believed what Dr A had said with no significant efforts made to undertake a full and proper investigation.

89. Mrs L raised concerns about Dr A’s communication during her appointment on 13 July. She first reported this to the Trust’s Patient Experience Team on 16 July while recovering in hospital following surgery to remove her fallopian tube.

90. The Trust began its formal complaints process after Mrs L escalated the matter in October 2024.

91. During the investigation, the Trust contacted Mrs L, speaking with her by telephone on 10 October and emailing her the same day to acknowledge the complaint and summarise its understanding of the issues.

92. The Trust issued its response on 16 January 2025. It explained that it had interviewed Dr A and reviewed the medical records to reach its conclusions. The Trust said that Dr A’s communication may have caused confusion.

93. While it did not agree that Dr A confirmed the pregnancy was viable, it did find that they had incorrectly interpreted the 11 July 2024 records as showing no ectopic pregnancy. In the response, the Trust apologised for this error, noting the ectopic pregnancy was apparent from the tests and associated medical notes.

94. The Trust also accepted that Dr A advised further tests were needed, despite the ectopic pregnancy already being confirmed on 11 July. It recognised this inconsistency contributed to Mrs L’s confusion.

95. We are sorry to hear Mrs L is dissatisfied with the internal complaint process. We understand how frustrating it must be to think your complaint has not been dealt with in an honest and transparent way.

96. Our Principles of Good Complaint Handling state that organisations should be open and accountable, provide evidence based explanations, and give clear reasons for their decisions. They must also investigate complaints thoroughly and fairly.

97. These principles require organisations to be transparent about the steps they take, the evidence they rely on, and how they reach their conclusions.

98. They should not minimise or downplay failings when they are identified, and they should support staff to be honest when things go wrong.

99. An investigation should involve reviewing relevant records, speaking to the staff involved, and considering the complainant’s account. Organisations should also ensure apologies are meaningful and acknowledge the impact on those affected.

100. We have considered Mrs L’s concerns about transparency. Transparency requires an organisation to explain what it has done, what evidence it relied on, and how it reached its conclusions.

101. In this case, the Trust set out the steps it took, including interviewing Dr A and reviewing the clinical records, and explained how this informed its findings. We consider this meets the standard of transparency expected under our Principles of Good Complaint Handling.

102. We also looked at whether the Trust attempted to minimise the failings identified. The Trust acknowledged that Dr A incorrectly interpreted the 11 July records, accepted that his communication contributed to Mrs L’s confusion, and apologised for this.

103. It also outlined the learning identified and the actions taken. These are not consistent with an organisation attempting to minimise errors or avoid accountability.

104. The Trust’s response addressed the concerns it had acknowledged at the outset and apologised for Mrs L’s experience and confirmed that Dr A would reflect on his practice, improve his communication, and ensure clearer documentation of clinical discussions and decisionmaking.

105. For us to find that the Trust showed a lack of transparency or attempted to cover up wrongdoing, we would need to see evidence that it failed to consider relevant information or reached conclusions that were not reasonably supported by the evidence available.

106. We recognise Mrs L disagrees with parts of the Trust’s conclusions. However, this does not indicate a lack of transparency or an attempt to minimise failings. Our role is to assess whether the Trust followed a fair process and reached a decision that was reasonable based on the evidence.

107. Whilst we recognise that we have reached a different outcome to the Trust, we cannot say that it did not follow a fair process.

108. Taking this into account, whilst ultimately reaching an outcome we do not agree with, we are satisfied the Trust acted in line with our Principles of Good Complaint Handling. It addressed the key issues, apologised to Mrs L, and outlined the learning and improvements arising from the complaint.

109. We consider that it addressed the substance of her concerns and based its conclusions on the available evidence. We have not seen any signs of maladministration or service failure in how the Trust handled her complaint.

Conclusion

110. For the reasons outlined above, we will not be taking any further action on Mrs L’s complaint about the Trust.

111. We understand this decision may be disappointing for Mrs L, especially given the time and effort she has invested. We thank Mrs L for bringing her complaint to us and appreciate the opportunity to consider it.

1. We have carefully considered Mrs L’s complaint about Dorset Healthcare University NHS Foundation Trust (the Trust). We were saddened to hear of the events Mrs L complains about, how she continues to deal with these issues and how the worry of these issues has impacted her life.

2. Mrs L stated the Trust informed her that her pregnancy was viable when it was not, and she was shouted at by a doctor (Dr A), when she questioned this. Having reviewed the available evidence we have seen there were indications of failings in how Dr A has communicated with Mrs L and that it was reasonable for her to have believed her pregnancy was viable.

3. We have also seen the Trust has taken steps in line with what we would expect to see, to put this right.

4. We have seen no evidence of maladministration with how the Trust has dealt with the complaints process or the communications held following the complaint being raised.