Leeds Teaching Hospitals NHS Trust

6. Mrs E complains about care and treatment the Trust provided to her in 2022. Specifically, that:

• staff failed to refer her to a consultant or provide clear expert guidance for management of her second trimester miscarriage • staff recommended surgical management, but when she was ready for theatre two days later the consultant advised against surgical management.

7. Mrs E also complains about the Trust’s handling of her complaint. She says the Trust was dismissive of her concerns, directed her complaint to the wrong department twice, and delayed responding.

8. Mrs E says the lack of proper care and guidance from the Trust resulted in a delay in treatment, and she had to knowingly carry her deceased baby for eight days.

9. Mrs E told us she experienced significant trauma and distress. She says she should have been allowed to focus on processing her loss, rather than trying to make decisions that were not truly choices at all. Mrs E says she is having counselling because of the trauma she experienced.

10. Mrs E says the way the Trust handled her complaint compounded her pain and distress. She says she re-lived the trauma when her complaint was passed around, and she has spent two years fighting to be heard and for the Trust to acknowledge its mistake.

11. Mrs E is seeking an acknowledgement of the failings in her care, an apology, service improvements, and a financial remedy as an outcome to the complaint.

12. Mrs E had an ultrasound scan in 2022. Sadly, this identified she had miscarried her baby.

13. A few days later, Mrs E’s mother spoke with the unit to discuss options for management of the miscarriage. She opted for medical management.

14. Mrs E saw a trainee GP the following day, had a further scan and discussed the management options available. Mrs E opted for surgical management and this was arranged.

15. Mrs E saw a consultant gynaecologist two days later. Both management options were discussed again. Mrs E opted for medical management and she was given mifepristone (a medicine used for medical management of miscarriage).

16. Mrs E attended the Trust two days later and gave birth to her baby.

Management of miscarriage

20. Mrs E says the failures and delay in the care and treatment she received, meant she had to carry her deceased baby for eight days. She says staff did not refer her to a consultant or provide clear expert guidance for management of her miscarriage.

21. The Trust says an initial wait, was to allow Mrs E to consider her options and for her to feel ready about her next steps. It says given how upset Mrs E was, a nurse felt it was too soon to discuss her options on how to manage the miscarriage and she was given a leaflet explaining the different options and contact numbers for the unit when Mrs E felt ready to discuss the options.

22. NICE guidance on ectopic pregnancy and miscarriage says:

‘Support and information giving

‘Treat all women with early pregnancy complications with dignity and respect. Be aware that women will react to complications or the loss of a pregnancy in different ways. Provide all women with information and support in a sensitive manner, considering their individual circumstances and emotional response.

Healthcare professionals providing care for women with early pregnancy complications in any setting should be aware that early pregnancy complications can cause significant distress for some women and their partners.’

23. The guidance also says:

‘Expectant management

Use expectant management for 7 to 14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. Explore management options other than expectant management if:

• she has previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage).’

24. Mrs E was diagnosed with a delayed miscarriage at 12+6 weeks gestation during a scan.

25. The Trust noted she was understandably too emotional to discuss treatment options straight away. The discussion was deferred to a later date. It is also noted Mrs E was asymptomatic at this point. The Trust gave her information about treatment options for management of the miscarriage to read when she was ready.

26. It was appropriate for the Trust to defer discussing options for management of the miscarriage until Mrs E was ready. Input from a consultant or an expert was not needed at this point. The Trust’s management is in line with guidance from NICE when supporting women with early pregnancy complications.

27. Two days later, Mrs E’s mother called the unit with Mrs E present for the call to discuss treatment options. The Trust documented Mrs E had read the relevant leaflet and she was considering a manual vacuum evacuation (MVA) as she wanted a postmortem examination. This is a surgical procedure for early miscarriage (usually under 12 weeks), allowing the uterus to be emptied using gentle suction carried out under local anaesthetic.

28.  The Trust advised Mrs E that MVA was not suitable at her gestational age and surgical management should better be done under general anaesthetic.

29. Our adviser said the Trust’s advice was correct as MVA is best suitable for a gestation under 12 weeks. This consultation is well documented and is a good standard. The Trust appropriately discussed the available options and Mrs E decided to have medical management.

30. Mrs E says that the following day staff recommended surgical management, but when she was ready for theatre two days later the consultant advised against surgical management.

31. NICE guidance says:

• ‘Offer medical management to women with a confirmed diagnosis of miscarriage if expectant management is not acceptable to the woman.

• Explain what expectant management involves and that most women will need no further treatment. Also provide women with oral and written information about further treatment options.

Medical management

For the medical management of missed miscarriage offer:

• 200 mg oral mifepristone.

Surgical management

Where clinically appropriate, offer women undergoing a miscarriage a choice of:

• manual vacuum aspiration (MVA) under local anaesthetic in an outpatient or clinic setting or • surgical management in a theatre under general anaesthetic.’

32. Mrs E saw a GP trainee the next day. The notes show they discussed both medical and surgical management and the risks and benefits of each. Mrs E opted for medical management and the Trust obtained her consent for that. Our adviser said the information given was appropriate and escalation to a senior doctor was not required.

33. Mrs E changed her decision later the same day and expressed a preference for surgical management. She explained her initial choice of medical management was influenced by the belief that it might increase the likelihood of obtaining answers regarding her miscarriages through a post-mortem examination.

34. Our adviser said the GP trainee appropriately advised Mrs E that at such an early stage, a postmortem maybe inconclusive and likely that a cause for the miscarriage may not be established.

35. Following this discussion, Mrs E opted for surgical management as she would find medical management difficult to process. The Trust booked Mrs E for surgical management two days later.

36. NICE guidance does not specify how quickly a Trust should perform surgical management after a patient has made the decision. But as noted above, expectant management could last as long as 14 days. Our adviser said the decision to treat Mrs E within two days of her appointment with the GP trainee is appropriate timing.

37. Mrs E spoke with a gynaecology nurse on the telephone the next day. She said she was having second thoughts and was undecided about surgery. The Trust noted that despite her second thoughts she wanted surgical management, and that she said she felt like surgery would be the best option for her mentally. The nurse arranged for Mrs E to return to the unit the next day for the procedure and noted she was free to change her mind at any time.

38. Mrs E was admitted the following day for surgical management. Mrs E saw a consultant gynaecologist who explained that after 12 weeks gestation, the recommendation is to have medical management due to the higher risk of complications with surgical management. The consultant documented they told Mrs E surgical management was still an option if she wanted to proceed with surgery.

39. The Trust discussed the risks with her and, after a family discussion, Mrs E opted for medical management. The Trust gave her mifepristone. The Trust admitted her for the second stage of medical management two days later. Mrs E was discharged later the same day.

40. Mrs E says a lack of care and guidance resulted in a delay in treatment, and she had to knowingly carry her deceased baby for eight days. We recognise how distressing the events were for Mrs E and understand how difficult this time was for her. It was understandable Mrs E was unsure what management route she wanted, especially as she wanted a postmortem to help identify a possible reason for the miscarriage and earlier miscarriages.

41. We recognise how hard things were for her in those eight days. From her perspective she was left to navigate a heartbreaking decision without adequate support, and without proper guidance or care. She felt the advice she received from the consultant was different and that the initial advice was incorrect. We accept Mrs E was very upset, distressed, and confused. Nothing we have said in this report is intended to dismiss the extremely sad circumstances of this case, nor to undermine the heartbreak she felt. We know what happened has made it difficult for her to process her loss.

42. We have listened to what Mrs E told us and considered the Trust’s records. Mrs E’s views do not necessarily align with the Trust’s records, and we have not dismissed either of those versions of events. Considering all of the evidence, including the clinical advice, we cannot say the Trust acted outside of the relevant guidance. It gave Mrs E adequate time to first process the upsetting news of the miscarriage. The advice and support it gave throughout her journey was correct and clinically appropriate, and in line with NICE guidance. We have therefore, found that the Trust’s management of Mrs E’s care was in line with NICE guidance.

Complaint Handling

43. Mrs E says the Trust was dismissive of her concerns, directed her complaint to the wrong department twice, and delayed responding. She told us the complaints process caused further upset and distress at an already, difficult time.

44. Mrs E feels the Trust did not listen to the essence of her complaint, and it cannot take learning or improvement if no one is taking responsibility for the mistakes made. She says she feels the Trust has not acknowledged the full extent of its mistakes in its complaint response or taken learning from what happened.

45. The NHS complaints standards say a complaints process should be:

‘Thorough and fair when looking into complaints and:

• gives an open and honest answer as quickly as possible, considering the complexity of the issues

Give fair and accountable responses that:

• set out what happened and whether mistakes were made • fairly reflect the experiences of everyone involved • clearly set out how the organisation is accountable • give colleagues the confidence and freedom to offer fair remedies to put things right • take action to make sure any learning is identified and used to improve services.’

46. The complaint standards also say staff should demonstrate a clear understanding of when the main issues are for the person who has made the complaint.

47. On 13 December 2023, Mrs E raised an online enquiry via PALS asking for a senior manager to contact her to discuss her concerns. The enquiry was brief and Mrs E noted the events were difficult to write down.

48. PALS processed the enquiry as a PALS concern to try to resolve informally, rather than share it with the Trust’s complaints team to be investigated formally.

49. Following advice from gynaecology, PALS shared Mrs E’s enquiry with the nursing department. On 18 December, a senior nurse spoke with Mrs E and told PALS the concerns were not regarding nursing.

50. The nurse asked PALS to forward concerns about sonographers to radiology and told PALS to redirect the concerns to two members of staff as Mrs E wanted a more formal investigation. We have not seen any evidence the nurse sent the complaint to the complaints team directly as noted in the Trust’s response as this was not part of the complaints file.

51. Following instruction from the nurse, PALS passed Mrs E’s concerns onto the patient experience team and asked for the PALS concern to be allocated to radiology given the concerns Mrs E had outlined about sonography in her call with the nurse.

52. On 21 December, the complaint team acknowledged the complaint. A complaints handler emailed Mrs E on 29 December to arrange call to discuss her complaint following unsuccessful attempts to reach her on the phone. A call was scheduled for 11 January.

53. Mrs E emailed the Trust’s chief executive on 11 January expressing disappointment that a scheduled call did not take place in the morning. She said she had spent all week preparing given the upsetting nature of her complaint.

54. A complaints handler emailed Mrs E the following day on 12 January. An apology was given for not calling as scheduled due to work commitments and a further date was scheduled for a call.

55. A complaints handler spoke with Mrs E on 19 January. They advised an expected date for a complaint response on or before 15 February and that they would update Mrs E if there were any possible delays.

56. The complaint handler sent four updates between 2 February and 12 March. The last update noted the response would be ready within a few days once approved by the chief executive. The Trust posted its response on 13 March.

57. Mrs E contacted the complaint handler on 31 March and said she was still waiting for response.

58. Between 2 and 23 April, the Trust identified its response dated 13 March had not been delivered despite the correct address. It sent an electronic copy to Mrs E via email and the Trust raised this internally with the postal service. The missing correspondence does not form part of Mrs E’s complaint. We have therefore, not considered this as part of the Trust’s handling of the complaint but have added it for context.

59. Mrs E discussed her outstanding concerns with a complaint handler on 30 July. The complaint handler emailed her on 1 August following the call and said they would send an update by 13 August for an estimated timescale for a response.

60. On 5 August, a complaint handler sent an email to Mrs E with an anticipated date for a response of 1 October or sooner if possible.

61. A complaint handler sent Mrs E an update on 19 September. The email noted the complaint handler was waiting on some information. Once received, the information would be drafted into a response and sent to the Trust chief executive for a review. An expected date for a response was noted as on or before 22 October.

62. The complaint handler arranged a call with Mrs E on 24 September at her request. Following the call, the complaint handler contacted the relevant teams with updates to the existing complaint.

63. A complaint handler sent a further update email to Mrs E on 8 October. The email noted its response was with quality assurance before going to the chief executive for sign off. The complaint handler apologised for the delay and said an expected date for a response was on or before 5 November.

64. Mrs E emailed the complaint handler on 21 October. She asked the Trust to send its response with either a security password or a secure postal method, either recorded delivery or signed for post. The complaint handler confirmed the response would be sent via recorded delivery and confirmed the address the same day.

65. A complaint manager emailed Mrs E on 31 October. The email noted the response was with the Deputy Chief Nurse for a review and it would then be sent onto the Chief Nurse for a final review and sign off. The email noted the complaint handler would update Mrs E on their return to the office the following week.

66. On 4 November, a complaint manager told Mrs E the response would be sent in post the same day. Mrs E contacted the complaint handler on 25 November requesting an electronic copy of the Trust’s response. The complaint handler emailed this the next day.

67. We acknowledge the complaint process was not easy for Mrs E. Although a complaint process can take some time especially where multiple disciplines and complex issues are involved, the Trust did update Mrs E in a timely manner as we would expect. We have not identified significant delays in the handling of Mrs E’s complaint.

68. The Trust has acknowledged some mistakes in the handling of Mrs E’s complaint including directing her complaint to the wrong department on two occasions. The Trust says it identified one staff member responsible for the mishandling of the complaint when it was first received by PALS.

69. The Trust apologised and said the member of staff had been given further training and supervision to ensure the mistakes are not repeated. The errors had been discussed with the member of staff concerned and they were told care must be taken to contact the correct team when using the PALS process when a concern is received.

70. The member of staff was also reinforced the importance of reviewing all concerns fully to ensure that concerns that are serious or complex are passed on to the complaints team. Additionally, the PALS team have been given training aids and further information to assist them when reviewing concerns.

71. Mrs E’s case was discussed with the team and they were made aware that poor communication and an incorrect review of concerns can affect the service provided and cause patients and relative’s unnecessary distress. The Trust has apologised for the upset and anxiety this caused Mrs E and recognised how difficult it may have been for her to send her concerns to the team.

72. With regards to the planned call that should have taken place on 11 January 2024, the Trust apologised for this. It said it would share feedback with the complaints team to highlight the importance of ensuring contact is made at the times agreed and remind the team to check their diary each morning to ensure there are no clashes to prevent this happening again.

73. We acknowledge the Trust’s efforts to learn and implement changes to prevent similar issues. Although these events were deeply distressing for Mrs E, we believe the Trust has responded to her concerns in full and made meaningful service improvements.

74. We acknowledge the events were and continue to be incredibly distressing for Mrs E. We acknowledge Mrs E’s view that the Trust was dismissive of her concerns. The Trust did take account of Mrs E’s concerns and the impact the events had on her. Its responses reflect the events, and reflect our views set out above that it did not do anything wrong during the management of her miscarriage. The Trust answered and acknowledged her concerns. We do not consider the Trust was dismissive of her concerns. It acted in line with our NHS Complaints Standards.

75. When a senior nurse spoke to Mrs E on 18 December 2023 and told PALS the complaint should be sent to the complaint team, PALS redirected the complaint to the patient experience team to action and to radiology for it to contact Mrs E in an attempt to resolve her concerns about sonographers informally.

76. Although PALS tried to resolve concerns informally, we consider PALS should have sought more information from Mrs E about her concerns given the brief details on the online enquiry when received on 13 December 2023. This would have prevented the subsequent chain of events in the complaint being passed to two departments that were not involved and it being directed to the complaints team from the outset.

77. At this point of the process the Trust had not obtained a full understanding of the complaint in line with our NHS Complaints Standards. However, the complaint was passed to and acknowledged by the complaints team on 21 December within six working days. The Trust has already acknowledged the improvements it has implemented to ensure this happens going forwards.

78. A call was arranged to take place between Mrs E and a complaint handler on 11 January 2024. This did not happen and led to Mrs E to email the Trust chief executive. She expressed her disappointment and her email notes she had spent all week preparing for the call. Our Principles of Good Administration say organisations should do what they say they are going to do. If they make a commitment to do something, they should keep to it or explain why they cannot. The Trust failed to act in line with our Principles here.

79. We recognise work commitments may occasionally interfere with pre-scheduled tasks. We acknowledge the Trust’s apology to Mrs E for missing the call. The call was rearranged swifty and took place on 19 January.

80. We do not consider the above issues caused a significant delay to the complaints process, but we acknowledge the distress this caused Mrs E given the time she spent preparing to discuss upsetting and traumatic events and then discussing the complaint unnecessarily with two departments, causing her additional distress.

1. Mrs E says a lack of care and guidance resulted in a delay in treatment, and she had to knowingly carry her deceased baby for eight days. We recognise how distressing the events were for Mrs E and understand how difficult this time was for her.

2. The Trust was considerate of the circumstances. It gave Mrs E adequate time to first process the upsetting news of the miscarriage. The advice and support it gave her throughout her journey was correct and clinically appropriate. We have found the Trust’s management of Mrs E’s care was in line with NICE guidance.

3. Mrs E says the Trust directed her complaint to the wrong department twice, and it delayed responding. She says the Trust’s complaints process caused further upset and distress at an already, difficult time.

4. The Trust answered Mrs E’s concerns in full, reflecting the events. Although the complaint process took some time, the Trust updated Mrs E in a timely manner. The Trust did direct her complaint to other departments on two occasions when she initially raised the complaint in December 2023 rather than process it as a formal complaint and it did not call her as agreed on 11 January 2024. We do not consider these added any significant delay to the handling of the complaint.

5. The Trust acknowledged errors in its handling of Mrs E’s complaint. It implemented service improvements to prevent a recurrence and it apologised for the errors in its complaint handling. The Trust has agreed to pay Mrs E £200 to remedy the distress the redirection of the complaint on two occasions and a missed call had on her.

81. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

82. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

83. We have identified failings in the Trust’s handling of Mrs E’s complaint. The redirection of Mrs E’s complaint to different departments in December 2023 caused her distress having to discuss the complaint unnecessarily with two departments. She then spent time preparing to discuss upsetting and traumatic events with a complaint handler on 11 January 2024 which did not take place as planned, causing her additional distress.

84. We recommend that within four weeks of the date of our final report, the Trust pay ​Mrs​ ​E £200 in recognition of the inconvenience and distress the handling of her complaint caused her when the Trust received it on 13 December 2023 and the distress she experienced when a pre-planned call did not take place on 11 January 2024.

85. The Trust should send us evidence it has completed the recommendation we have made.

86. We recognise this has been a deeply painful and difficult experience for Mrs E and we are very sorry to hear about her loss.

87. This concludes our final report.