Royal Free London NHS Foundation Trust

6. Ms R complains about aspects of care and treatment she received from the Trust during her pregnancy in October 2024. Specifically, Ms R said the Trust:

• failed to maintain the agreed consultant led caesarean section plan • failed to address her concerns about the midwife’s behaviour in its complaint response • failed to acknowledge her initial complaint in a timely manner.

7. Ms R said the Trust’s actions caused her significant psychological distress during her pregnancy. She said the midwife’s attempts to change her caesarean section date exacerbated her PTSD. A condition that can cause flashbacks, fear and distress after a traumatic event and anxiety. This reminded her of her previous traumatic birth, when both she and her baby required intensive care.

8. Ms R said she experienced heightened fear and worry about harm to herself and her baby. This led to her crying at work and difficulty sleeping. She said the Trust’s actions made her feel targeted, unsafe and unsupported. She also said the situation undermined her confidence in the maternity service and has left her hesitant about accessing maternity care in the future.

9. Ms R is looking for an apology, accountability and service improvements. She is also looking for a financial remedy.

10. Ms R received maternity care from the Trust during her pregnancy in 2024. Ms R said she experienced a traumatic birth during an earlier pregnancy, after which she developed PTSD. She said she informed the Trust about this history during her pregnancy. Ms R said staff arranged for one consultant to oversee her care to provide continuity and reduce her anxiety.

11. On March 2024, Ms R attended her first antenatal appointment. She said a staff member confirmed she would remain under the care of an assigned consultant throughout her pregnancy. The consultant later booked her elective caesarean section for 22 October 2024.

12. Ms R attended an antenatal appointment on 2 October 2024 before her planned caesarean section. She said the consultant responsible for her care confirmed they would perform the surgery and did not discuss any possibility the procedure may move because of emergencies or theatre pressure.

13. On 3 October 2024, a Trust midwife telephoned Ms R and told her staff would move her caesarean section from 22 October to 19 October 2024. The Trust later explained staff reviewed maternity theatre capacity and emergency activity at the time. Ms R said she contacted her consultant after this conversation and later received confirmation her caesarean section would remain on 22 October 2024.

14. On 10 October 2024, Ms R attended a further antenatal appointment. She said she raised concerns about the earlier telephone call with a senior midwife, who checked the theatre schedule and confirmed the caesarean section remained booked for 22 October 2024.

15. On 14 October 2024, the same midwife telephoned Ms R again and discussed moving the date of her caesarean section. Ms R said this caused her distress because of her previous traumatic birth and PTSD. She also said the midwife told her she could not rearrange the surgery with another Trust consultant and did not refer her for a pre-operative assessment. Ms R said she contacted the senior midwife again following this conversation.

16. On 15 October 2024, Ms R made a complaint to the Trust through the Patient Advice and Liaison Service (PALS). She later completed the Trust’s formal complaint form on 21 October 2024.

17. Ms R said a senior midwife later confirmed the consultant responsible for her care would remain her main point of contact. Ms R attended the hospital for her pre-operative assessment and caesarean section on 22 October 2024. The Trust later provided its final complaint response on 25 November 2024.

Maintaining Ms R’s consultant led caesarean section plan

22. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

23. In her complaint to the Trust and to us, Ms R said the Trust failed to maintain the agreed consultant led caesarean section plan for 22 October 2024. She said staff contacted her on more than one occasion about moving the procedure date despite her previous traumatic birth experience and PTSD symptoms. She said this caused her significant anxiety and distress during pregnancy.

24. The Trust said maternity staff reviewed the theatre list because of emergency activity, theatre capacity, staffing pressures, and the clinical needs of other patients. It said consultants remained involved in decisions about theatre prioritisation throughout. They also said staff ultimately kept Ms R’s caesarean section booked for 22 October 2024 with the assigned consultant as originally planned.

25. We saw Ms R’s records showed staff planned her elective caesarean section for 22 October 2024 with the assigned consultant. We also saw staff were aware of her previous traumatic birth experience and associated PTSD symptoms.

26. CG192, section 1.2, says healthcare professionals should communicate clearly, support shared decision making, and take account of a woman’s preferences and individual circumstances when planning care. Section 1.4 says maternity care should be personalised and should take account of previous traumatic birth experiences and mental health needs.

27. Good medical practice says doctors must provide safe and effective care and give patients the information they want or need in a way they can understand. Leadership and management for all doctors says clinicians must allocate treatment and resources according to clinical need.

28. Our obstetric adviser explained elective caesarean section lists are regularly reviewed because maternity services are unpredictable. They said staff may need to reprioritise planned procedures because of emergency activity, staffing pressures, theatre capacity, or changes in another patient’s clinical condition.

29. The Trust said staff reviewed the theatre list because another patient required urgent surgery involving the same surgical team. We recognise Ms R questioned whether the surgery could have been urgent if staff discussed the changes in advance. Our adviser explained urgent maternity surgery does not always mean surgery must happen immediately. They said clinicians may still need to prioritise another patient whose condition becomes higher risk.

30. We therefore saw staff had reason to review the theatre list according to clinical need. We also saw staff contacted Ms R to discuss possible changes rather than changing arrangements without informing her. This was in line with CG192 regarding communication and shared decision making.

31. The records show the consultant later emailed maternity staff on 4 October 2024 stating Ms R’s surgery should not move from 22 October 2024. Although Ms R later received another call discussing possible changes, we saw the Trust ultimately maintained the agreed consultant led plan. The records show the assigned consultant carried out the surgery on 22 October 2024 as planned.

32. Our adviser said clearer documentation about Ms R’s trauma related needs may have reduced the anxiety caused when staff discussed possible changes to the theatre list. However, they also explained maternity services must balance individual birth plans against competing clinical demands affecting other patients.

33. We also saw staff considered Ms R’s previous traumatic birth experience and PTSD symptoms throughout these events. This was in line with CG192, sections 1.3 and 1.4. This says staff should recognise the impact previous trauma and anxiety can have during pregnancy and provide supportive and compassionate care to women experiencing mental health difficulties.

34. Having considered the available evidence, relevant guidance, and clinical advice, we saw staff reviewed theatre lists according to clinical need and ultimately maintained the agreed consultant led caesarean section plan. Staff did what we would expect in contacting Ms R about potential changes to her birth plan at the time they reviewed the Trust’s lists.

35. On this basis, we do not see indications something went wrong.

36. We recognise these events caused Ms R anxiety and upset during her pregnancy, particularly given her previous traumatic birth experience and PTSD symptoms. We hope we have clearly explained our decision, and this assures Ms R we carefully considered her concerns.

The Trust’s response about the midwife’s behaviour

37. In her complaint to the Trust and to us, Ms R said the Trust failed to properly address her concerns about the midwife’s behaviour during the complaint process. She said the midwife’s communication lacked compassion and worsened her anxiety during pregnancy.

38. The Trust said the midwife contacted Ms R whilst staff were reviewing maternity theatre capacity and planned procedures because of emergency activity and operational pressures. It also said the midwife contacted Ms R following discussions with senior clinical staff reviewing the theatre list.

39. The NHS Complaint Standards say organisations should respond to complaints openly, honestly, and proportionately. The standards say organisations should explain what happened, acknowledge where things could have been handled better, apologise where appropriate, and explain any learning identified.

40. CG192, sections 1.3 and 1.4, says healthcare professionals should recognise the impact previous trauma and anxiety can have during pregnancy. They should provide supportive and compassionate care to women experiencing mental health difficulties, including PTSD.

41. We saw the Trust acknowledged Ms R felt the communication was upsetting and lacked empathy. We also saw the Trust explained the context surrounding the telephone calls and why staff were reviewing the theatre list at the time.

42. The Trust said managers reflected with the midwife following the complaint regarding their communication and approach. It said the midwife recognised the distress caused and apologised for the impact the conversation had on Ms R.

43. This means we saw the Trust acknowledged where communication could have been handled better, apologised for the distress caused, and identified reflection and learning following the complaint. This was in line with the NHS Complaint Standards.

44. We recognise Ms R remained dissatisfied because she considered the Trust relied too heavily on operational pressures as an explanation for the communication she received. We also recognise these conversations were likely particularly distressing given her previous traumatic birth experience and PTSD symptoms.

45. We saw the Trust addressed the concerns raised, explained the circumstances surrounding the communication, apologised, and identified learning following the complaint response.

46. On this basis, we do not see indications something went wrong.

How long the Trust took to acknowledge Ms R’s complaint 47. In her complaint to the Trust and to us, Ms R said the Trust did not acknowledge her initial complaint in a timely manner. She said this increased her frustration and uncertainty at a time when she already felt distressed by her maternity care and previous traumatic birth experience.

48. We recognise these events were upsetting for Ms R. Her records show she explained to the Trust her previous birth experience continued to affect her emotionally and psychologically during her pregnancy. In these circumstances, clear and timely communication about her complaint was especially important.

49. The NHS Complaint Standards say organisations should acknowledge complaints at the earliest opportunity and consistently meet acknowledgement timescales. The standards also say organisations should explain the next steps in the complaints process and discuss how they will handle the complaint.

50. Section one in our Principles say organisations should follow their own policy and procedural guidance, whether published or internal.

51. In line with our Principles, we note the Trust sets out, publicly, how it deals with concerns raised to its PALS team and complaints raised to its complaint team.

52. The online PALS information says patients/complainants can contact this team with concerns. If they do, PALS offers a less formal route for addressing more immediate issues with their care. It provides contact details for the PALS team.

53. PALS aims to respond, in an informal way, within ten working days. If the patient/complainant remains unhappy after their discussions with PALS, they can make a complaint to the Trust’s complaints team.

54. The online complaints information explains, if the patient/complainant wants to make a formal complaint, they can contact the complaints team of the relevant hospital. This webpage also recognises a patient/complainant may want to do this if they are not satisfied with a response they have first received from a member of hospital staff, or the PALS team.

55. This webpage gives the contact details of the relevant complaint teams at the Trust, who can formally respond to complaints. The online complaints information explains the complaint team will acknowledge any complaint like this within three working days. We note this is consistent with the expectations set out in the NHS Complaint Standards and the Trust’s Complaint Procedure.

56. We saw Ms R emailed the Trust’s PALS team on 15 October 2024 with concerns about the actions of midwifes involved in her care. She also copied in a member of staff at the antenatal clinic. She did not copy in the Trust’s complaint team into this correspondence to raise her complaint with this team.

57. Four working days later, on 21 October, PALS arranged for Ms R to meet with a maternity department matron about her concerns, who she met that day. We saw this was within ten working days, and within the timeframe PALS should respond and address concerns as set out in the Trust’s procedure.

58. We appreciate the meeting Ms R had did not resolve things. As detailed in the Trust’s later, formal response, Ms R asked the matron for a written response to her complaint. In the meeting, the matron agreed to arrange for the Trust to provide such a response.

59. Acting on this agreement, after the meeting, we saw the matron emailed the Trust’s complaint team later the same day. They confirmed to the team what they agreed with Ms R in the meeting and registered her complaint for this team to respond.

60. This means, at the point Ms R felt PALS had not addressed her concerns and she wanted to complain further, the staff she met confirmed the Trust would respond formally in writing.

61. As this was an acknowledgement staff gave at the time she wanted to escalate her complaint, we consider she received confirmation the Trust would respond to it through its complaint process. Staff gave this at the point she confirmed she wanted to escalate to the complaint team.

62. This means we consider she received an acknowledgement the Trust would formally respond to her complaint within three days of confirming she wanted to escalate her complaint. This is in line with the Trust’s Complaint Procedure and the NHS Complaint Standards.

63. On this basis, we do not see indications something went wrong.

64. We recognise these events were very distressing for Ms R, particularly given her previous traumatic birth experience and PTSD symptoms.

65. We hope the above clearly explains why we saw the Trust’s staff acted in line with relevant guidance when reviewing the maternity theatre list and responding to the concerns Ms R raised.

66. We also hope our explanation helps bring Ms R some closure regarding why staff discussed possible changes to her caesarean section whilst ultimately maintaining the agreed plan.

1. We recognise Ms R has been through a difficult time. We appreciate Ms R told us the uncertainty surrounding her agreed caesarean section plan, together with the way the Trust handled her concerns, later exacerbated her post-traumatic stress disorder (PTSD) and anxiety and left her feeling unsafe and unsupported.

2. We have carefully considered Ms R’s complaint about the Trust maintaining her agreed consultant led caesarean section plan. Having done so, we saw staff continued to manage her care in line with relevant guidance, taking into account both her physical and psychological needs during pregnancy.

3. We have also carefully considered Ms R’s concerns about how the Trust responded to issues she raised about the behaviour of a midwife involved in her care. We saw the Trust considered and responded to the concerns she raised through its complaint process. We have not seen evidence of service failure in the way the Trust addressed this aspect of her complaint.

4. Finally, we carefully considered Ms R’s concerns about delays in the Trust acknowledging her complaint. We have not seen evidence any delay here amounted to a service failing.

5. Overall, having carefully considered all aspects of Ms R’s complaint, we saw staff acted in line with relevant guidance and standards. This means we have decided not to investigate Ms R’s complaint further. We hope the explanations we provide about this later in our statement assure Ms R we took all her concerns seriously.