Manchester University NHS Foundation Trust

5. Miss T complains about the care and treatment that she received from Manchester University NHS Foundation Trust (the Trust) between February and March 2023, immediately before and after her caesarean on 18 February 2023. She specifically complains that:

• she did not have another risk assessment immediately before she was discharged from hospital on 20 February 2023• she was not given the correct dose of anti-coagulant medication after she was discharged from hospital• she developed deep vein thrombosis (DVT) and needed compression stockings but had to wait a week for the prescription.

6. Miss T says as a result of the Trust’s actions, she suffered blood clots which were diagnosed a fortnight afterwards.

7. She says if the Trust had carried out a further risk assessment and given the correct dose of anti-coagulant, including assessing the strength of the medication by reweighing her, this might have led the Trust to consider prescribing higher strength anticoagulants which would have lessened her chances of getting blood clots.

8. She also says as a result of the Trust’s delay in prescribing the compression stockings, she suffered more swelling in her upper thigh and was in immense pain. Miss T says she now has to elevate her legs and wear compression stockings daily and she struggles to stand for long periods.

9. Miss T is seeking a financial remedy.

10. Miss T had a caesarean on 18 February 2023 and was discharged home on 20 February 2023.

11. On 7 March 2023 Miss T attended A&E as she had developed left leg pain and swelling.

12. Miss T had a scan on her left leg on 8 March 2023, which confirmed the presence of deep vein thrombosis (DVT - is a blood clot in a vein, usually in the leg) and the Trust created a treatment plan.

13. Miss T was discharged from hospital on 9 March 2023 and compression stockings were recommended. Miss T received her prescription compression stockings on 16 March 2023.

Risk assessments

17. Miss T complains she did not have another Venous Thromboembolism (VTE) risk assessment immediately before she was discharged from hospital on 20 February 2023. A VTE risk assessment is a standard evaluation for all pregnant women to determine their risk of developing blood clots. Clinicians use standardized tools to score risk based on a number of factors such as age, pre-existing health conditions, and length of hospitalisation during pregnancy.

18. Miss T says if the Trust had carried out another VTE risk assessment shortly before she was discharged from hospital, the length of her hospitalisation may have contributed to her risk score and may have led the Trust to prescribe a stronger dose of anticoagulant medication.

19. The Trust explained it had carried out timely VTE risk assessments and if Miss T’s risk score had been reassessed, accounting for the additional risk factor of the length of her hospital admission, her risk level would have remained in the intermediate category resulting in no additional doses of anticoagulant medication.

20. According to the NICE Antenatal Care guidance, clinicians should carry out a VTE risk assessment at the first antenatal appointment, and after any hospital admission or significant health event during pregnancy.

21. The Trust’s guidelines on VTE Prophylaxis in Pregnancy and the Puerperium say although most VTEs occurs antenatally, the risk per day is greatest in the weeks immediately after delivery. As such, further risk assessments should also be carried out in the postnatal period.

22. The records show that Miss T had a risk assessment on 31 July 2022 at her first antenatal appointment, in accordance with NICE Antenatal Care guidance. Our midwife adviser said Miss T’s risk was correctly assessed as minor at the time of her first antenatal appointment as she was over 35 and had assisted reproductive technology, IVF.

23. The Trust’s guidelines do not specify exactly when the VTE risk assessments should be undertaken in the postnatal period, however we can see that following Miss T’s caesarean on 18 February 2023, she had a further VTE assessment at 11.02am which placed her at an intermediate risk of VTE. She had two further VTE assessments on 19 February 2023 at 00:05am and 20 February 2023 at 04:12am which also placed her in the intermediate category. Our midwife adviser said Miss T’s VTE risks assessment scores were correctly calculated.

24. As the Trust’s guidelines or the NICE guidance does not specify a set amount of VTE risk assessments to be carried out but instead, key stages for assessments as mentioned above, our midwife adviser said Miss T’s VTE risk assessments were timely and there was no requirement to undertake a further VTE risk assessment prior to her discharge from hospital.

25. We have considered Miss T’s assertion that the duration of her hospital admission would have resulted in additional doses of anticoagulant medication.

26. Records show that Miss T was admitted for her elective caesarean on 18 February 2023 at 08:36am. Her baby was delivered on 18 February, and they were discharged home at 10:30pm on 20 February. This equates to 62 hours in hospital and according to our midwife adviser, a hospital duration of two and a half days would unlikely be a factor in determining her VTE risk.

27. We acknowledge Miss T’s concerns about the risk assessments she had and understand that she wanted to ensure she received the right number of risk assessments, and for this to be reflected in the strength of her anticoagulant medication.

28. We can see the Trust acted in line with the NICE guidance and its own guidelines with the VTE risk assessments it carried out antenatally and postnatally. There was no requirement for the Trust to carry out a further assessment prior to Miss T’s discharge from hospital, and her hospital duration would unlikely have been a risk factor. As such, we find no failings in relation to this aspect of the complaint.

Anticoagulant dose

29. Miss T complains she did not have the correct number of doses of anticoagulant medication after she was discharged from hospital and complains about the strength of the medication she was given; she says the cumulative impact of these issues increased her chances of developing DVT.

30. Regarding the number of doses of anticoagulant medication, we note that Miss T was given a 10- day course of anticoagulant on 20 February upon discharge from hospital. On 28 February 2023 she contacted the ward to explain that she had found one bent needle and had dropped another on the floor prior to administering and asked the Trust to replace the two needles. She complains that she did not receive the replacement needles to make up the 10-day course, due to the Trust’s error in prescribing the replacement doses.

31. The Trust explained that it followed the wrong process in requesting extra syringes. It said, when prescribing medication on its system, the order goes directly to the pharmacy department once approved by the ward pharmacist. It is then dispatched from the pharmacy department to the ward where the staff can dispense to women. It said Miss T’s medication did not arrive on the ward because it was erroneously prescribed as though she was still an inpatient; her request was routed incorrectly within its systems, and the pharmacy department did not receive it.

32. The Trust explained that its normal procedure for requests for medication post- discharge is to update a communication book so that the midwife on shift is aware of the request. It said when the medication did not arrive on the ward for Miss T, staff should have contacted the pharmacy department and updated Miss T about the delay and updated its communication book.

33. According to the RGOC Guidelines No. 37a, the standard of care is a 10-day course of prophylactic (preventative) anticoagulation following a caesarean.

34. Our haematologist adviser said with an incomplete 10-day course the risk of developing a blood clot is higher than if the course had been completed as the aim of the anticoagulation is to reduce the risk of developing a blood clot, such as DVT. However, our adviser also said completing a 10-day course does not remove the risk of developing blood clots completely.

35. Given that the RGOC Guidelines No. 37a state that a 10-day course is required, once Miss T had notified the Trust that she was two doses short, it should have made arrangements to ensure that she had the full course. The Trust did not do this, and we consider this to be a failing.

36. Miss T has explained the steps she took to replace the two defective doses, such as ringing the Trust on two occasions ahead of the course running out and visiting the hospital after being told she could collect the missing doses. Despite her efforts, Miss T did not receive the replacement doses so she could not take them.

37. The NHS website on anticoagulant medications says anticoagulants reduce the chance of someone developing blood clots. They do not remove the risk of someone developing clots.

38. Therefore, we cannot say that if Miss T had completed her course that she would not have developed DVT. However, we can say that the Trust missed the opportunity to reduce her risk when it did not provide the two replacement doses of anticoagulants. We have considered whether this risk can be measured and to what extent it would have increased Miss T’s risks of getting DVT.

39. Our haematologist adviser said it is difficult to measure the amount that Miss T’s risk of developing DVT was increased and as such, it is difficult to ascertain a clear impact. This is because there are no clear studies looking at the development of blood clots according to anticoagulation during or following a caesarean.

40. As patients can still develop blood clots after a full course of anticoagulants, we therefore cannot conclude that Miss T’s DVT was caused by, or how much her risk was increased by, not having the complete 10-day course of anticoagulant. We can say that there was a missed opportunity by the Trust to reduce Miss R’s risk of developing DVT.

41. Miss T would have understandably been concerned she was two syringes short of the 10-day course of anticoagulants and frustrated that the Trust did not fulfil her request to make up the missed doses. This would likely have caused Miss T some distress, especially heightened by a diagnosis of DVT a week after requesting the two replacement doses. Miss T was left wondering whether she would have developed DVT anyway if she had been able to complete the recommended 10-day course.

42. We can see that the Trust has apologised for not replacing the missed doses requested by Miss T. However, we consider the Trust still needs to do more to put right the impact caused by this failing. Therefore, we have made a recommendation for this at the end of this report.

43. With regards to Miss T’s complaint about the strength of her medication, she says she was not reweighed during her third trimester, and this goes against the Trust’s guidelines which recommends reweighing women at 36 weeks of a pregnancy for weight-adjusted anticoagulation dosing following delivery. Miss T says if she was reweighed, she would have been prescribed a stronger dose of anticoagulant, and this would have reduced her risk of getting DVT.

44. The RCOG guidelines No. 37a say clinicians should use the booking weight or most recent weight to guide anticoagulation dose and we can see from the records that Miss T’s booking weight was used to inform the strength of her anticoagulant medication.

45. The Trust’s guidelines recommend considering re-weighing women around 36 weeks to guide risk assessment and dosing of anticoagulation, but this is not mandated by the Trust nor is this a requirement in the RCOG guidelines No. 37a.

46. Our haematologist adviser said Miss T’s anticoagulant dosing was measured in line with guidance. According to our haematologist adviser, if Miss T had been reweighed at 36 weeks, it is likely her weight at that point would have been higher than her weight following delivery, so this may not have been the most accurate way to calculate her anticoagulation dose, and she may have ended up with a higher dose than she needed. Our haematologist adviser also said even if Miss T had been given a higher weight-based dose post-delivery, the risk of developing a blood clot still exists.

47. We understand Miss T’s frustration that the Trust did not consider reweighing her at 36 weeks, including the vagueness of its guidance pertaining to reweighing and weight-based anticoagulating prescription. We note that the Trust have confirmed it is looking at improving the clarity of its guidance in this area.

48. We consider it was appropriate for the Trust to use Miss T’s booking weight in line with the RCOG guidelines No. 37a. As such, we have not found any failings with the strength of Miss T’s anticoagulant medication.

Compression stockings

49. Miss T complains she was not given compression stockings after discharge from hospital and had to wait a week for them.

50. We note that Miss T attended A&E on 7 March 2023 due to pain and swelling in her left leg and a scan on 8 March confirmed the presence of DVT. The Trust recommended a treatment plan and some compression stockings. Miss T was discharged on 9 March and received the prescription for her stockings on 16 March 2023.

51. The Trust explained that a referral was made to the community orthotics team (clinical specialists who design and fit medical devices to support the body) for Miss T’s compression stockings. It said in hindsight, it should have provided an outpatient prescription for Miss T so that she could have collected the stockings from her local chemist.

52. The RCOG’s guidelines No. 37b say, following a diagnosis of DVT, graduated elastic compression stockings should be worn on the affected leg to reduce pain and swelling. The guidelines do not specify timescales for providing stockings following a DVT diagnosis, but our haematologist adviser says ideally, it should be as soon as possible after a blood clot is diagnosed.

53. The GMC Good Medical Practice guidance says doctors should promptly provide or arrange suitable advice, investigations, or treatment where necessary.

54. As the RCOG guidelines No.37 say that stockings should be provided as treatment for DVT, and the Trust did not provide these until a week later, we consider this was not in line with the GMC guidance as treatment was not provided promptly. As such, we consider this to be a failing.

55. Miss T says as a result of the Trust’s delay in prescribing the compression stockings, she suffered more swelling in her upper thigh and was in immense pain. Miss T says she now has to elevate her legs and wear compression stockings daily and she struggles to stand for long periods.

56. Our haematologist adviser said there is limited evidence on how well compression stockings reduce the risk of developing long-term damage to the veins after suffering DVT, and compression stockings are not given solely for this reason. Therefore, we cannot say that Miss T has been caused any lasting impact from the Trust’s delay in providing the stockings.

57. However, our haematologist adviser explained that compression stockings provide symptomatic benefit to some patients due to the increase in external pressure they give to the leg. The above RCOG guideline also says that stockings reduce pain and swelling.

58. Therefore, we can say that Miss T likely suffered more pain and swelling than she otherwise would have, while she waited for her prescription.

59. We can see the Trust has apologised to Miss T for the delay in issuing her prescription for her compression stockings. It also said it will discuss her case with nursing and medical staff who discharged her from hospital to ensure that all patients in future who require compression stockings are discharged with them or that there is a clearly documented plan in place to collect them.

60. We welcome learning from the outcomes of complaints, however we consider the Trust still needs to do more to put right the impact caused by this failing. Therefore, we have made a recommendation for this at the end of this report.

61. We were sorry to hear of the circumstances of Miss T’s delivery and the DVT that she developed. We appreciate that this was a difficult and distressing time for her when she had just had a baby.

1. Miss T complains about Manchester University NHS Foundation Trust’s (the Trust) care and treatment. We appreciate the circumstances surrounding Miss T’s caesarean section (caesarean) was stressful for her and were sorry to hear of the ongoing impact this has had on her.

2. We have not found any failings in the risk assessments that were carried out prior to Miss T’s discharge from hospital on 20 February 2023 and the weight-based calculation of the strength of Miss T’s anticoagulant medication.

3. We found a failing with the Trust’s handling of Miss T’s request for two replacement doses of her anticoagulant medication and the length of time Miss T had to wait for compression stockings. We have found that this led to a missed opportunity to reduce the risk of Miss T developing DVT, and increased pain and swelling than she otherwise would have, while she waited for her stockings.

4. We can see that the Trust have already apologised for these failings, but we consider more needs to be done to put right the injustice caused. Therefore, we recommend the Trust pay Miss T a total of £650.