County Durham and Darlington NHS Foundation Trust

4. Mrs Y has raised concerns about aspects of care and treatment she received at County Durham and Darlington NHS Foundation Trust (the Trust) between April 2022 and July 2023. She specifically says:

• the Trust kept her on an induction drip for four hours unnecessarily • five days after the birth of her son, she suffered a pulmonary embolism and was placed on enoxaparin for three months however, she feels given her experience she should have been placed on this medication for six months • when the Trust prescribed her with three months of enoxaparin and she was told she would be referred to the haematology and respiratory departments. These appointments did not occur until February 2023 and July 2023. Mrs Y feels she was not referred correctly.

5. Mrs Y says her caesarean section should have been carried out four hours earlier. She adds being on the induction drip for longer than needed unnecessarily increased her risk of having a postpartum haemorrhage.

6. Mrs Y says due to the failings with the drip she suffered a haemorrhage in which she lost 3.5 litres of blood, had to undergo five blood transfusions, was placed in ICU (intensive care unit), and had to be put into an induced coma.

7. Mrs Y feels if she had been placed on enoxaparin for six months instead of three, she would not need to be on apixaban medication for life.

8. She says being on apixaban for life has impacted her life in that she cannot drink alcohol, flying on a plane is problematic, and she struggles to play with her children.

9. Mrs Y says she has lost complete faith and trust with the Trust and has now moved her care to another trust.

10. Mrs Y also adds this experience affected her ability to breastfeed, to hold her baby, and she could not be left alone with her newborn. Mrs Y adds she feels this impacted the quality time with her youngest son and childhood years with her older children. She says this had a severe impact on her mental health in that she is now being assessed for post-traumatic stress disorder (PTSD) and she felt nobody cared.

11. Mrs Y wants a full investigation, service improvements and a financial remedy.

12. Mrs Y was pregnant with her third child.

13. On 28 April 2022, Mrs Y attended the Trust as due to having gestational diabetes (high blood sugar that develops during pregnancy and usually disappears after giving birth) it was agreed she would not go past 38 weeks pregnant and was therefore scheduled to be induced on this day.

14. At 8.20am on 28 April 2022, the Trust broke Mrs Y’s membranes (the sac of fluid surrounding the baby) as part of the induction process. At 9.35am the Trust decided to start Mrs Y on a drip of syntocinon (synthetic form of oxytocin, used to induce labour) at 10am the drip started.

15. At 2.05pm, the Trust reviewed Mrs Y and found the baby had moved position and was now lying in a transverse position (horizontally in the uterus).

16. At 4.04pm on 28 April 2022, Mrs Y’s third baby was born by caesarean section.

17. Following her caesarean section, she suffered a haemorrhage and had a blood transfusion on 28 April 2022.

18. On, 6 May 2022, Mrs Y was discharged home with the Trust agreeing to refer her to the respiratory and haematology department.

19. A few days later Mrs Y developed a pulmonary embolism (PE, a blood clot in the lungs) and was prescribed 12 weeks of enoxaparin (a blood thinner).

20. On 5 July 2022, Mrs Y was seen in the obstetrics clinic prior to her 12-week course of enoxaparin ending.

21. On 30 August 2022, Mrs Y attended A&E as she was suffering from chest pain. The Trust diagnosed her with having another PE. It is at this point the Trust made a respiratory and haematology referral.

22. On 7 September 2022, Mrs Y attended A&E again as she was short of breath again. The Trust diagnosed her as having anxiety.

Induction

27. Mrs Y has raised concerns the Trust left her on an induction drip for four hours unnecessarily as her baby had moved into a transverse position and therefore would not be able to be delivered vaginally.

28. We understand Mrs Y’s concerns about this and knowing potentially her caesarean section could have been done four hours previously. We are saddened to hear her describe the birth trauma she experienced.

29. The Trust says within its response that before Mrs Y’s membranes were broken the baby was in the ‘perfect’ position for birth to happen vaginally, which is why it continued with the induction process.

30. Mrs Y’s medical records show at 8.20am on 28 April 2022 the Trust undertook an abdominal palpitation which showed the baby was in a longitudinal position and head was down. We understand the midwife then undertook a vaginal examination and broke Mrs Y’s membranes. The medical records from the vaginal examination show the baby was presenting headfirst.

31. At 9.35am, Mrs Y was seen by a doctor, who decided to start her on a syntocinon drip and planned for a further vaginal examination after four hours of starting the drip. Mrs Y’s records document she was happy with this plan.

32. Mrs Y’s syntoconin drip was started at 10am and was reviewed at 2.05pm, which is in line with the plan of a review every four hours. The Trust carried out a vaginal examination and found the baby had moved to a transverse position. This was confirmed by an ultrasound scan.

33. The Trust acted in line with the NICE guidance which says, ‘Ensure the position of the baby and the woman's condition are suitable for induction by:

• abdominally assessing the level and stability of the fetal head in the lower part of the uterus at or near the pelvic brim.’

34. We consider the Trust did this by carrying out an abdominal and vaginal examination to feel the baby’s position prior to rupturing Mrs Y’s membrane’s and beginning the induction drip.

35. Our obs and gynae adviser says whilst there is no national guidance covering the length of time a syntocinon drip runs during the induction process before further examination occurs, four hours is standard practice, and this is what occurred here.

36. We also consider this is what was agreed with the doctor and the Trust examined Mrs Y four hours after the drip started.

37. Our obs and gynae adviser also says whilst a baby can move following the beginning of the induction process it is rare and so it would not be expected for the Trust to carry out any further examinations on the position of the baby prior to commencing the syntocinon drip.

38. We consider there is no evidence of a failing here. The Trust appropriately examined Mrs Y prior to starting the syntocinon drip, and as it would be rare for a baby to change position at this stage, there was no indication at this point to carry out a further examination.

39. We hope this offers Mrs Y some reassurances about the care she received and that despite her baby moving positions, the Trust noted this at the earliest time.

Enoxaparin prescription

40. Mrs Y has raised concerns she was only prescribed with enoxaparin for three months instead of six.

41. We are sorry to hear about the experience Mrs Y had following the birth of her son. We recognise Ms Y had questions about the medication she was given to help her which added trauma and upset at an already distressing time.

42. The Trust says the recommended treatment for a pulmonary embolism postnatally is three months of an anticoagulant medication.

43. Mrs Y’s medical records show she received enoxaparin for three months following the birth of her son.

44. The RCOG guidance says, ‘Therapeutic anticoagulant therapy should be continued for the duration of the pregnancy and for at least 6 weeks postnatally and until at least 3 months of treatment has been given in total. Before discontinuing treatment, the continuing risk of thrombosis should be assessed.’

45. Based on the above guidance we consider enoxaparin can be prescribed for a period of between three and six months. Our haematology adviser says the decision about how long someone needs to be on enoxaparin would be based on their clinical symptoms.

46. Mrs Y’s medical records do not show any concerns about breathing difficulties, and she was seen in the obstetrics clinic prior to her three month prescription ending. Our haematology adviser says there is no guidance on this but as Mrs Y did not have any clinical symptoms which would suggest she needed further treatment, the Trust made the appropriate prescription of enoxaparin.

47. We consider there is no failing here. Whilst guidance does say someone can be placed on enoxaparin for six months, we can see no reason why Mrs Y should have had a longer prescription.

48. We also consider it is important to note our haematology adviser says even if Mrs Y had been on enoxaparin for six months it would not mean that she would not have had another pulmonary embolism. Another blood clot could have formed once the medication had ended. They also added as Mrs Y had suffered from one pulmonary embolism, she was at higher risk of having another.

49. Whilst this is not the finding Mrs Y was looking for, we hope the above information offer her some reassurance.

Referrals

50. Mrs Y complains the Trust did not appropriately make her referrals to the haematology and respiratory departments.

51. We understand how worrying this was for Mrs Y given she had a traumatic experience whilst she was in hospital giving birth to her son.

52. The Trust has apologised for not arranging all appointments following her discharge.

53. Mrs Y’s medical records show she was seen in the obstetrics clinic at the Trust prior to her three months of enoxaparin ending on 5 July 2022.

54. This is in line with the RCOG guidance which says a patient in Mrs Y’s situation should have a follow up in an obstetrics or haematology clinic.

55. In Mrs Y’s discharge letter the Trust says she will be referred to the respiratory and haematology department. However, these referrals were not made until 1 September 2022. As Mrs Y was discharged on 6 May 2022, this is a delay of four months for her respiratory referral.

56. We consider this to be a failing.

Impact

57. Mrs Y says due to this delay she now needs to be on apixaban for life which impacts her ability to fly, drink alcohol and play with her children.

58. The RCOG guidance does not say Mrs Y needed to be seen by a respiratory consultant. Our physician adviser confirmed the delay in the respiratory referral would have had no impact on Mrs Y’s physical health as she was seen in the obstetrics clinic on 5 July 2022, which is in line with guidance. We make the distinction of physical health here recognising what Mrs Y has told us about how her mental health continues to be affected by the whole birth and post-natal experience.

59. However, we do consider as the Trust told Mrs Y a respiratory referral would be made this caused her to lose faith in the Trust and worry about any future care she may need to receive from the Trust. This is because the Trust has not done what it has said and understandably led Mrs Y to question whether some parts of her care and treatment are missing.

1. Mrs Y has raised concerns she was left on an induction drip for four hours unnecessarily and the Trust only prescribed her with three months of enoxaparin when this should have been six months. We have not seen any evidence of a failing within these complaints and consider the Trust has acted appropriately and in line with guidance.

2. Mrs Y also raised concerns about a delay with her respiratory and haematology referrals. We consider there has been a failing here as the Trust said it would make these referrals following her discharge. Whilst we do not consider this has had any impact on Mrs Y’s health, we do consider it has impacted her trust and faith in the Trust.

3. We hope Mrs Y finds reassurance and further information about why the Trust provided certain treatment and made certain decisions.