Barts Health NHS Trust

4. On behalf of Ms T, Mr Z complains about the care the Trust gave his wife when she attended its Emergency Department (ED) needing an emergency induction on 25 April 2025. Specifically, he alleges staff delayed giving her pain relief and commencing her induction. He also complains staff did not update his wife enough about next steps in her care and the timescales this involved.

5. Mr Z says his wife experienced avoidable pain and distress during the delay. The lack of updates left her uncertain and anxious about the safety of her and her baby during the delay. These memories have stayed with her and continue to cause anxiety whenever the family discusses her baby’s birth.

6. Mr Z says his wife wants the Trust to acknowledge its failings and improve its service, so it does not repeat them. She also seeks financial remedy for the impact of the events on her.

7. Ms T attended the Trust’s Triage Unit at 3pm on 25 April 2025. The Trust categorised her as an ‘emergency’, which meant she needed urgent labour induction.

8. She waited six hours in the Triage waiting room until a midwife saw her at 9pm. During this time, Ms T experienced contractions.

11. To decide if we should conduct a detailed investigation into a complaint, we first consider whether there are any indications something went wrong with the service provided by the organisation. If so, we then explore what impact these things had, and whether the organisation has done enough to address this. We can also consider if the organisation would be willing to take further steps to put things right and resolve the complaint.

12. As we saw the Trust recognised and apologised for all the failings Ms T alleged in paragraph four, we can see indications of failings on all these matters. This means we focused our analysis on whether the impacts she describes link to these indications of failings.

13. Due to the delay in commencing her induction and getting pain relief, Ms T says she experienced avoidable pain and distress. We recognise labour is painful. Therefore, by not expediting the process and providing timely pain relief to ease her pain, we can see why her labour was longer, more painful and more distressing than it would otherwise have been had there not been these delays.

14. We can appreciate how the Trust’s lack of communication in this situation would have left Ms T anxious and uncertain about what care she would receive and when. We can appreciate this would have made her concerned about her safety and that of her baby. We can see how all this would have left her with distressing memories of what happened during her labour.

15. So, we can see the impacts she describes link to the failings she described. We therefore went on to consider whether the Trust has done enough to put this right.

16. We use our Principles for Remedy to consider whether an organisation has addressed injustice and put things right. We should also have regard for the outcome(s) the complainant seeks.

17. Where an organisation cannot put someone back in the position they would have been in had the poor service not occurred, our Principles for Remedy say the outcomes Ms T is seeking are appropriate remedies. Therefore, we looked at whether the Trust has provided these things already.

18. During the course of its investigation, we note the Trust confirmed there was a significant delay in initiating Ms T’s labour induction and it did not give her timely pain relief. The Trust recognised its failings and apologised to Ms T for not having communicated the reasons for such a long delay clearly on the day of the events complained about.

19. This means we can see the Trust has already acknowledged the failings Ms T raises with us. Therefore, it has already provided the acknowledgments of what went wrong that she seeks.

20. Regarding service improvements, to learn lessons from what happened and improve, our Principles for Remedy say organisations can do any combination of the following:

• revise procedures to prevent the same thing happening again • train or supervise staff.

21. The Trust’s final outcome letter explained its deputy associate director of midwifery and senior leadership reflected on what happened with the midwifery team involved. Regarding the delayed induction and lack of communication, they reinforced to staff the importance of prescribing induction medication during the initial consultation.

22. By implementing this service improvement as a learning experience due to Ms T’s complaint, they aimed to reduce unnecessary delays and facilitate a better patient experience. The Trust also confirmed its deputy midwifery director would monitor this new directive and ensure all staff follow it up through regular audits.

23. Concerning the delay in administering Ms T pain relief, the Trust’s deputy midwifery director met with the staff involved. They explained the need for these staff to provide stronger and timely pain relief for contractions.

24. Having considered the above, we can see the Trust has taken the sort of supervisory action our Principles for Remedy recommend to try and prevent the mistakes staff made happening again. This means the Trust has already done what we would expect to improve its service on the matters Ms T raised with us.

25. Having said that, the Trust did not provide a financial remedy. Ms T seeks one. Our guidelines around remedy indicate this is appropriate. This means we saw there was more the Trust could do to remedy the injustice to Ms T. We explain further below.

26. We identified the delays in Ms T’s induction and pain relief caused her both distress and pain. So, we consider this to be the primary and most severe impact. Therefore, we considered what financial remedy may be appropriate to address her complaint based on this injustice. Our Guidance on Financial Remedy says we usually determine financial remedies based on the primary injustice we see.

27. Our Guidance on Financial Remedy suggests the delay in offering pain relief during the emergency labour induction process fits into level two of our severity of injustice scale. Level two physiological impacts include when the person affected experiences ‘severe pain lasting no more than one week’.

28. This is the kind of injustice we identified on this matter. We consider Ms T’s avoidable pain to be severe because it related to her labour. The pain relief staff later provided to manage it was strong pain medication which needed to be prescribed by hospital doctors. As the delay giving this pain relief happened over the course of a few hours, the avoidable pain was less than a week in duration. In level two cases, we recommend financial remedies between £120 and £550.

29. To decide on a level of financial remedy, along with our severity of injustice scale, we review similar cases where the person involved experienced similar injustice. Following this review, we concluded the Trust should pay Ms T £150 in recognition of the injustice we described in paragraphs 25 to 28.

30. Having considered the evidence and reaching a view on the impact in this case, we considered we had an opportunity to try and resolve this case without the need for a detailed investigation.

31. We shared our thinking with both Ms T and the Trust. As our guidelines indicated £150 is an appropriate financial remedy, we asked the Trust whether it would pay Ms T this amount. We also shared our proposed resolution with Ms T.

32. The Trust replied to us and agreed to pay Ms T this financial remedy. However, Ms T told us this was not enough and would not accept this resolution. She wanted a higher amount, above £1,000.

33. Given we proposed a resolution our guidelines indicated as suitable and Ms T declined it, we did not see the outcome she wanted to address the impact we saw was attainable. On this basis, given the Trust had done everything else we expected, we decided not to consider her complaint further.

34. We are very sorry Ms T and her husband experienced such a distressing and painful experience when Ms T gave birth to their child. We recognise the emotional and physical discomfort this caused both.

35. We recognise the resolution we proposed does not go as far as they hoped. We hope we have explained the thorough consideration we gave to our proposed resolution and why we have decided not to consider the case further.

36. We would like to thank Ms T and her husband for bringing their concerns to our attention and appreciate their efforts in reliving those difficult moments whilst we worked on their case.

1. We have carefully considered Ms T’s complaint about her care and treatment during her induction labour process at Barts Health NHS Trust (the Trust).

2. We have reviewed all the evidence and decided the Trust has already done enough to put right the impact of these events on Ms T, apart from providing financial compensation. However, since Ms T is unhappy with the level of financial redress we consider appropriate to resolve the complaint, we have decided not to take any further action.

3. We recognise how important her concerns are for Ms T, and we do thank her for the time and efforts it took in bringing those to our attention.