Lewisham and Greenwich NHS Trust

2. Mrs W complains about the maternity care the Trust provided to her following a 20 week scan in 2024. She specifically complains the Trust:

• refused her request to be transferred to another hospital • persuaded her to go ahead with a rescue cerclage procedure by providing false reassurance • ruptured her membranes during this rescue cerclage procedure • did not provide appropriate care and treatment following the procedure • communicated poorly throughout and • provided poor bereavement support.

3. Mrs W very sadly lost her baby a few days later. She says what happened has had a profound impact on her emotional wellbeing and caused her immense grief and emotional pain. She also says it has made it impossible for her to move on or regain a sense of normalcy.

4. Mrs W says the pregnancy was the result of IVF treatment and her and her partner need to pay for further treatment to try and get pregnant again. She says she has been unable to work due to the trauma and emotional toll of what happened which has compounded the financial strain.

5. Mrs W would like the Trust to acknowledge what went wrong, apologise, make service improvements and pay her a financial remedy.

6. Mrs W became pregnant in 2024 following successful IVF treatment. We understand Mrs W and her partner had been trying for a baby for many years, and she had previously suffered an early miscarriage.

7. Mrs W attended the Trust for her 20 week scan at 19+5 weeks pregnant. This is one of two scans the NHS offers women during pregnancy. It is also called the anomaly scan as it is used to look for several conditions in the baby as well as check their growth. It usually takes place between 18 and 21 weeks.

8. During Mrs W’s scan, the sonographer noted her cervix (the neck of the womb) was open. The cervix acts as a protective barrier for the baby. It is usually closed, firm and long until late in pregnancy when it begins to soften, thin and open to prepare for labour. An open cervix at 19 weeks can increase the risk of preterm labour and pregnancy loss.

9. The Trust admitted Mrs W to hospital and performed a rescue cerclage procedure (a ‘stitch’) the next day. This is where a suture is placed around the cervix. The aim being to strengthen the cervix, so it maintains its length and preserves the mucus plug which protects the baby against infection.

10. Unfortunately, Mrs W’s membranes (the protective layers surrounding the baby) ruptured during the procedure releasing amniotic fluid (a waterlike substance that surrounds and protects the baby). Mrs W gave birth the following day (day 3) and her baby very sadly died the day after. We cannot begin to imagine what an incredibly difficult time this was.

15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this with Mrs W’s complaint and seen no indications anything went seriously wrong.

Communication with Dr A

16. Mrs W says she saw Dr A on admission (day 1), and they initially told her she would give birth that day and that her baby would not survive. She says she found this distressing and it made her feel pressured to have the rescue cerclage procedure. We can see from Mrs W’s medical notes that she raised these concerns at the time.

17. GMC Good Medical Practice say doctors must treat patients with kindness, courtesy and respect. It says doctors should communicate sensitively and considerately particularly when sharing potentially distressing issues about prognosis and care. It also says doctors should be willing to explain their reasons for the options they offer and any recommendations they make.

18. Dr A’s notes outline Mrs W’s history, findings on examination and the plan going forward. The plan being to start progesterone pessaries (to prevent contractions) and admit her for observation, bloods tests and a possible rescue cerclage procedure. Dr A’s notes do not detail any discussion with Mrs W.

19. Mrs W says Dr A told her she ‘would’ give birth that day. In their statement to the coroner, Dr A says they told her she ‘could’ go into preterm labour. We know an open cervix at 19 weeks can indicate cervical insufficiency which can lead to complications such as preterm labour. If Dr A said there was a risk of preterm labour this would be correct advice.

20. Mrs W says Dr A told her there was ‘no’ chance her baby would survive. Dr A says they told her the baby would not survive ‘if’ she went into preterm labour. We know a baby is generally not viable at 19 weeks. If Dr A said the baby would not survive at 19 weeks this would also be accurate advice.

21. We can see Mrs W told staff Dr A did not introduce themselves and she found them forceful, indifferent, unfriendly and unprofessional. She also said they did not acknowledge her emotions and left her feeling distraught and overwhelmed. Dr A says they broke the news as sensitively as possible and said they were sorry for what was happening.

22. Complaints about staff attitude usually involve two differing accounts of what happened with little or no corroborating evidence. It can therefore be difficult for us to reconcile those accounts and come to a firm view on what happened. It can be even more difficult to come to a view on how something was said.

23. Differing accounts can sometimes be the result of different perceptions of someone’s manner and behaviour. We also recognise Mrs W was going through an incredibly distressing situation at the time. This could have made communication even more challenging and taking in information difficult.

24. Overall, we do not think we can be sure Dr A’s attitude fell below the standards set out in GMC Good Medical Practice. We recognise Mrs W says they left her feeling pressured to have a rescue cerclage procedure. The clinical records show she had lengthy conversations with two other doctors before consenting to the procedure which is reassuring.

Mrs W’s request for transfer to another hospital

25. Mrs W complains the Trust refused her request to be transferred to another hospital. She says she wanted to go elsewhere as she had lost faith in the Trust due to her experience with Dr A.

26. We cannot see any reference to Mrs W asking to go to another hospital on day 1 or 2. The notes show another doctor saw her after Dr A on day 1. She told them she was upset Dr A had said she would give birth that day and her baby would not survive. They say the doctor apologised and had a long discussion about her situation and reassured her she was under no pressure to have the rescue cerclage procedure.

27. We think the second doctor responded appropriately to Mrs W’s concerns. They apologised for her experience and had a lengthy conversation with her about what was happening and what her options were. They also offered to arrange a conversation with a consultant and directed her to raise a complaint if she wished.

28. Dr B then saw Mrs W and her partner on day 2 and noted their concerns about Dr A. The notes say Dr B also offered an apology and talked them through what was happening and the options available. During a discussion with a consultant following discharge, Mrs W said her partner asked Dr B about being transferred to another hospital and Dr B reassured them they would look after her.

29. Mrs W’s notes show her partner asked a doctor if there was any benefit to moving to another hospital following an ultrasound on day 3. The doctor explained treatment would be the same at any other hospital. Our adviser confirmed the Trust’s plan to stay in hospital for 7 days, complete a course of antibiotics, continue progesterone and have a repeat scan at 22 weeks was appropriate.

30. Overall, the way clinical staff responded to Mrs W’s concerns about what happened with Dr A looks to be in line with the section of GMC Good Medical Practice noted in paragraph 17. The two doctors who saw her after Dr A apologised for what happened and had detailed conversations with her about her situation and next steps.

Communication around Mrs W’s condition

31. Mrs W complains staff told her that her cervix was open but provided conflicting information about how open it was.

32. We have looked at Mrs W’s maternity notes. At 1pm on day 1 a midwife noted she had been transferred to the delivery suite. It says Mrs W had attended for an ultrasound, but her cervix appeared open. The note says an examination in triage showed her cervix was 1cm open.

33. Dr A saw Mrs W at 2.31pm and noted her cervix was 1cm dilated on examination. The second doctor saw her at 11.30pm and also noted her cervix was 1cm dilated on admission. Dr B saw her at 10.05am on day 2 and noted her cervix was 1cm open on examination. The notes from the emergency cerclage procedure also say Mrs W’s cervix was 1cm open.

34. Overall, Mrs W’s notes say the cervix was 1cm dilated. We cannot see anything to indicate any other measurement. We note the records also reference Mrs W’s cervix being 2cm long. It may be these two measurements understandably caused some confusion at the time.

Communication around next steps

35. Mrs W complains staff provided her with conflicting information about what should happen now her cervix was open.

36. On day 1 Dr A noted the plan was to give Mrs W progesterone pessaries, admit her for observation and blood tests, and possibly a rescue cerclage procedure. We can see a note by a midwife then says Mrs W asked to speak with Dr A again as she was not clear on the plan and felt conflicted.

37. A note by another midwife says Dr A went to speak with Mrs W again and she then understood what was happening. The second doctor then noted a long discussion with Mrs W that evening. Their notes say they explained that if she went into labour, they would not usually intervene to save the baby before 22 to 24 weeks.

38. The note also they discussed the rescue cerclage procedure and the risks involved. It says they told Mrs W her cervix could remain as it is, or she may go into labour. It says Mrs W asked if she could be examined again the next day to reassess her cervical length. It says the doctor reassured her they could rediscuss her wishes again in the morning.

39. Dr B then spoke with Mrs W and her partner on day 2. Their notes say they had a long discussion about what had happened the day before and the options going forward. These being no intervention, conservative management (wait and watch) with progesterone pessaries or an emergency cerclage procedure.

40. Overall, we have seen evidence Mrs W was initially unclear on what was happening and what her options were. This could indicate poor communication, but further discussion is sometimes needed when explaining detailed information particularly in a distressing situation like this.

41. We do not think we can say communication fell below the standards set out in GMC Good Medical Practice. Mrs W’s records show the second doctor and Dr B had detailed discussions with her to ensure she had all the information she needed. This would be in line with GMC Good Medical Practice and meant any confusion or uncertainty was addressed.

Consent for emergency cerclage procedure

42. Mrs W complains Dr B told her and her partner that incidents sometimes happen during emergency cerclage, so her partner initially refused. She says they asked Dr B when the baby could survive, and they said 22 or 24 weeks. She says her partner therefore asked if she could remain in bed for two weeks and then be reviewed again.

43. Mrs W says Dr B said 'no' and that they had to do the procedure as she could get an infection or have a miscarriage. She says Dr B then did another examination and said there would be no problem as her cervix was long. Mrs W says her and her partner only agreed to the procedure because of Dr B’s false assurances.

44. Mrs W’s notes detail two lengthy discussions about the procedure. The second doctor who saw her on day 1 noted a long discussion about the pros and cons versus conservative management. They discussed what the procedure involved and the risks which included pain, bleeding, infection and rupture of membranes.

45. The second doctor’s note says they told Mrs W her cervix could remain as it is, or she could go into labour. It says they said she may not be able to do the procedure if her cervix continued to shorten, her membranes ruptured, she had any bleeding or she went into preterm labour.

46. Dr B then saw Mrs W and her partner on day 2. Dr B’s notes say they explained they may not be able to stop her going into labour if the cervix continued to shorten and babies born before 24 weeks do not survive. They also explained they could try to prevent preterm labour by inserting a stitch.

47. The notes say they explained examinations showed Mrs W’s cervix was open but with good length so they would recommend a stitch. They told her they could not guarantee the stitch would work or that there would be no complications. They also told her there was an increased risk of infection with an open cervix.

48. Dr B’s notes say Mrs W and her partner understood what they were saying but remained worried as they had been trying for a baby for a long time. Dr B therefore carried out a further examination and confirmed they could attempt a stitch based on the findings of this examination.

49. Clearly, there are two very different accounts of what happened during the discussion with Dr B. Mrs W says they told her and her partner the procedure would be fine as she had a long cervix. Dr B’s notes say they told them they could attempt the procedure, and it was the best option, but not without risk.

50. NICE guideline 25 says doctors should consider emergency cerclage when women between 16 weeks and 27+6 weeks pregnant have a dilated cervix and exposed unruptured membranes. It also says doctors should explain to the woman and their family the risks of the procedure and that it aims to delay birth.

51. Overall, it appears the Trust appropriately offered Mrs W emergency cerclage in line with NICE guideline 25. The notes show Mrs W’s cervix was 1cm open and her unruptured membranes exposed but not bulging. It also appears appropriate conversations took place prior to the procedure which outlined what was involved and the possible risks.

52. The second doctor’s note says they outlined the procedure and listed the risks including rupture of membranes. Dr B’s note from day 2 says they talked Mrs W and her partner through the options available and that, while they recommended rescue cerclage, they were clear complications can occur.

53. We have also seen the consent form Mrs W signed on day 2. This lists the ‘significant, unavoidable or frequently occurring risks’ of the emergency cerclage procedure as ‘bleeding, infection, damage to membranes/rupture membranes, miscarriage, injury to bladder/bowel’.

54. A note by a midwife after the procedure says Mrs W’s partner was concerned about the discussion that took place prior to the procedure. He said Dr B told them the risk of the membranes rupturing was minimal. We understand the risk would have been low due to Mrs W only being 19 weeks pregnant and 1cm dilated with no bulging membranes.

The emergency cerclage procedure

55. Mrs W complains she suffered spontaneous rupture of membranes during the emergency cerclage procedure which led to her losing her baby.

56. Mrs W’s notes show there was evidence of ruptured membranes on the last stitch during the procedure. Our adviser said there is nothing within the notes to indicate the rupture of membranes was due to an error by the Trust. They explained it is an accepted complication of the procedure.

57. The notes show the Trust used the ‘McDonald technique’. This is where the doctor grasps the cervix with forceps, inserts a suture as high as possible around the cervix in a purse-string fashion and then tightens it to close the cervix. It is a widely used surgical procedure for cervical cerclage.

58. We have not seen anything to suggest the rupture of membranes happened due to a failing by the Trust. It performed a widely used technique and a known complication very sadly occurred towards the end of the procedure. We understand rescue cerclage carries inherent risk because dilation has already occurred making the membranes fragile and more easily ruptured.

59. Overall, it appears the Trust’s care and treatment was in line with NICE guideline 25 and GMC Good Medical Practice which says doctors should promptly provide suitable treatment where necessary. We sincerely hope this provides Mrs W and her partner with some peace of mind.

Mrs W’s care and treatment after the procedure

60. Mrs W complains staff did not explain what was happening after the procedure, did not provide urgent treatment, failed to monitor her baby and did not address her concerns about the lack of amniotic fluid.

61. Mrs W’s maternity notes say Dr B reviewed her following the procedure alongside another doctor. They discussed the rupture of the membranes and that it was a potential risk of the procedure. They explained the stitch had been removed due to the risk of infection and there was also a risk of miscarriage.

62. Dr B’s notes say they advised Mrs W she would need close monitoring due to the risk of infection. They said Mrs W could be managed conservatively if she remained stable and the pregnancy continued with no evidence of infection. They started her on antibiotics and requested blood tests.

63. NICE guideline 25 says to offer women with rupture of membranes antibiotics for 10 days or until the woman is in established labour (250mg erythromycin four times a day). We can see the Trust did this. Dr B prescribed antibiotics after they saw Mrs W following the procedure on day 2.

64. NICE guideline 25 says to use a combination of clinical assessment and tests to diagnose infection in women with ruptured membranes. It says to do blood tests and measure foetal heart rate using cardiotocography (CTG). CTG is a technique used to monitor foetal heartbeat and uterine contractions.

65. The Trust kept Mrs W in hospital for assessment and carried out appropriate blood tests to check for infection. Our adviser said CTG monitoring was not possible in Mrs W’s case as she was only 19 weeks pregnant. CTG monitoring is typically done from 28 weeks onwards.

66. There is a note of a discussion with another doctor on day 2. It says Mrs W had a mild headache and could not feel the baby move. Mrs W’s partner asked the doctor when they would ‘evacuate’ the pregnancy and the doctor said they were not at that stage.

67. The doctor explained the first step was to monitor Mrs W’s observations, see if she had any pain and carry out blood tests to check for infection. They said they would do an ultrasound the following day if she remained well to assess the fluid around the baby as well as how the baby was doing.

68. The doctor also talked Mrs W and her partner through the risks going forward and in what situation they would offer a termination. The doctor advised them to rest overnight and let the midwife know if Mrs W experienced any pain or had any other concerns. We can see midwives later noted pink liquor (watery fluid) on her sanitary pads.

69. Mrs W had an ultrasound on day 3, and a doctor spoke with her and her partner shortly after to go through the results. These very sadly there was no amniotic fluid. The note says the doctor extended their sympathies, explained the poor prognosis and outlined the options were to either terminate or continue the pregnancy. They opted to continue.

70. We understand Mrs W’s own doctor said she should have also had a scan on day 2 to check the amniotic fluid. Our adviser said guidance does not specifically recommend an urgent ultrasound. They also said Mrs W’s care would have been the same if she had a scan the day before as there is little doctors can do when a woman’s membranes rupture at 19 weeks.

71. The Trust’s plan was for Mrs W to stay in hospital, continue progesterone, complete a course of antibiotics, receive ongoing monitoring and have a scan at 22 weeks. Our adviser confirmed this is what should happen. It is in line with GMC Good Medical Practice which says doctors must adequately assess the patient’s condition and promptly provide appropriate investigations or treatment.

72. Mrs W experienced bleeding later in the evening of day 3. A doctor attended and carried out a speculum examination. They saw foetal parts and explained she would likely miscarry shortly. Mrs W gave birth later that evening and her baby very sadly died in the early hours of day 4.

73. Overall, Mrs W’s care and treatment looks to be in line with NICE guideline 25 and Good Medical Practice. The Trust kept her in hospital for monitoring, continued progesterone, started antibiotics, carried out blood tests and performed an ultrasound. We understand there is sadly little more doctors can do at 19 weeks pregnant.

74. GMC Good Medical Practice say doctors must give patients the information they want or need to decide. It says this will usually include diagnosis and prognosis, uncertainties about these, options for treating or managing the condition, the nature of each option and the potential benefits, risks, and likelihood of success for each option.

75. We can see several discussions took place between doctors and Mrs W and her partner following the procedure on day 2. From what we have seen, these conversations clearly outlined what happened during the procedure, what this meant in terms of the risk to Mrs W and her baby and what the options were going forward.

Mrs W’s bereavement care

76. Mrs W complains about the Trust’s bereavement care. She says it was lacking, and she struggled to reach staff.

77. NBCP standards aim to ensure all bereaved parents and families receive consistently high-quality, compassionate and personalised care following pregnancy loss or the death of a baby. They were developed by Sands which is a charity that supports anyone affected by the death of a baby.

78. NBCP standards are not currently mandatory in the NHS in England. However, they are used in the NHS in Scotland, Wales and Northern Ireland, as well as by some NHS Trusts in England. They provide a useful guide to what good bereavement care should look like. They say:

‘1. All bereaved parents and families are provided with personalised care.

2. All bereaved parents and families have access to an appropriate, available and accessible bereavement room.

3. All bereaved parents and families are offered opportunities to make memories.

4. All bereaved parents and families are informed about and, where needed, referred for emotional support and for specialist mental health support.

5. A system is in place to clearly signal to all health care professionals and staff that a parent has experienced a bereavement.

6. Bereaved parents and families are confident that learning from their baby’s death will take place and are fully informed throughout.

7. Bereaved parents and families receive their care from an appropriately staffed team.

8. All staff involved in the care of bereaved parents and families receive the training and resources they need to provide high-quality bereavement care.

9. Healthcare staff are effectively supported to care for bereaved parents and families.’

79. Looking at Mrs W’s notes, we can see a midwife helped with memory making by taking photographs of her baby on day 4 as well as taking hand and footprints. We can also see staff moved her to the dedicated space for families grieving the loss of a baby on the morning of day 5.

80. A bereavement midwife (Nurse A) visited Mrs W in hospital on the morning of day 6 and another bereavement midwife (Nurse B) telephoned her the following day. Mrs W said she was physically well, feeling okay emotionally and was being supported by her partner. They agreed to speak the following week.

81. Nurse B telephoned Mrs W four days later and she said she was well. They offered support with the funeral which Mrs W declined. They agreed to speak again the following week. A community midwife visited Mrs W the same day. She said she was struggling to sleep and had pain in her knees. They advised her to contact her GP and said they would contact her the following week.

82. The next day, a doctor referred Mrs W to the Trust’s preterm surveillance clinic to discuss transabdominal cerclage in any future pregnancies. This is where a strong synthetic band is placed around the cervix through an abdominal incision. The band provides the cervix with support, preventing it from opening prematurely during pregnancy.

83. A community midwife tried telephoning Mrs W eight days later but there was no response. Another community midwife tried visiting and telephoning the following day. Mrs W returned their calls later that day and they arranged a home visit for the following day.

84. We cannot see a record of this home visit. However, there is an email from a community midwife to a consultant six days later saying they had met Mrs W at her home. They asked the consultant if they had referred her to the preterm surveillance clinic. It therefore appears a home visit did take place.

85. During the call with Nurse B, Mrs W also asked to speak with the matron to discuss her experience in hospital. The midwife said they would email the matron about this. Mrs W says the matron did not contact her and we can see no record of any contact with them.

86. A bereavement midwife (Nurse C) telephoned Mrs W the day after the midwife’s email to the consultant. She said she was feeling well and both her and her partner were doing okay. She said she was waiting to hear from the funeral director. The midwife offered to contact them to find out what was happening. They also offered further signposting which Mrs W declined.

87. A community midwife tried telephoning Mrs W six days later but there was no answer. They noted she was in touch with the bereavement team and had been referred to the preterm surveillance clinic. They therefore said she could be discharged from maternity services.

88. Nurse B telephoned Mrs W six days after this. She said she was well in herself, and the funeral was going to be later that month. They agreed to a further call the next day as Mrs W was awaiting release forms from the medical examiner. They spoke again the next day, and Nurse B offered to contact the medical examiner.

89. Mrs W had an appointment at the preterm surveillance clinic that same day. She was to contact them if she became pregnant again. Nurse B tried to telephone Mrs W five days later but there was no answer. Mrs W had a telephone appointment with a consultant two days after this to discuss her experience in hospital.

90. Nurse B telephoned Mrs W a few days after the funeral. She said she was well and had no questions or concerns. She declined any further calls from the bereavement team, and Nurse B told her she could get in touch again if needed. We can see no record of any further contact after this date.

91. Overall, the Trust’s bereavement care looks to broadly be in line with NBCP standards. The Trust helped with memory making, moved Mrs W to its dedicated space for bereaved families, provided emotional and practical support, talked through what happened and directed her to appropriate sources of help.

92. We recognise the matron did not contact Mrs W to talk about her experience as she requested. The Trust recognised this and apologised in its complaint responses. We note Mrs W spoke with a more senior member of staff after her discharge to discuss what happened in hospital.

93. We hope our consideration goes some way in addressing Mrs W’s concerns and provides her and her partner with reassurance around what happened. We are incredibly sorry for what they went through and how this deeply it has impacted them. We would like to take this opportunity to wish them the very best for the future.

1. We have carefully considered Mrs W’s complaint about Lewisham and Greenwich NHS Trust (the Trust). We recognise the incredibly distressing circumstances and want to share our sincere condolences for the loss of her baby. We have seen no indications anything went seriously wrong with her care and treatment. We are therefore closing her case at this stage.