Chesterfield Royal Hospital NHS Foundation Trust

5. Mrs K complains about the maternity care she received at Chesterfield Royal Hospital NHS Foundation Trust (the Trust) between November and December 2024.

6. Specifically, she complains that:

• clinicians dismissed her headache symptoms which resulted in a delayed venous sinus thrombosis

• clinician did not provide adequate aftercare following a hypoglycaemic episode, which left her without monitoring and nutrition

• clinicians gave her incorrect treatment information, which meant her insulin levels remained uncontrolled, causing significant stress and anxiety

• a clinician discussed sterilisation with her at an inappropriate time, which she found very distressing

• clinicians failed to remove her stitches following her caesarean section, which led to a serious infection.

7. Mrs K says the standard of care left her feeling let down and traumatised, which has had a significant impact on her mental health and prevented her from fully enjoying the birth of her first child.

8. As outcomes to her complaint, Mrs K is seeking an apology, service improvements, and a financial remedy.

9. Mrs K was in her late twenties at the time of events and pregnant with her first child.

10. Mrs K had a medical history of hypertension, psoriasis and anxiety. She received a type 2 diabetes diagnosis in March 2022.

11. Clinicians admitted Mrs K as an inpatient November 2024, 31 weeks into her pregnancy. This followed concerns about the movement of her baby, high blood pressure and raised blood sugars.

12. Clinicians delivered Mrs K’s son, prematurely, by caesarean section in mid-December and transferred him to the to the neonatal unit.

13. Mrs K took her son home at the end of December, and clinicians readmitted her the following day with an infection on her caesarean incision.

14. Mrs K complained to the Trust in January 2025.

Blood clot

18. RCOG’s Green Top guidelines state that pregnant women admitted to hospital should be offered preventative medication to reduce the risk of blood clots. The guidelines also list factors including pre-eclampsia, women aged over 35 and a high BMI (body mass index) which increase the risk of clots and require preventative medication.

19. Mrs K complains she had persistent migraine symptoms when she was admitted as an inpatient in November 2024. She says a doctor dismissed her migraines as normal pregnancy symptoms and told her to manage with paracetamol. Mrs K says after significant advocacy on her part she was referred to neurology where a scan revealed a blood clot.

20. The Trust acknowledged Mrs K had reported having a headache for three weeks several months earlier and explained it advised her to contact the antenatal clinic if her symptoms worsened. It also said Mrs K did not report any further symptoms until her November admission at which point clinicians offered Oramorph (a powerful opioid painkiller) and a CT scan referral if the pain relief did not work. The Trust apologised that the discussions upset Mrs K and acknowledged her distress at having to push for further investigations.

21. Headaches are common in pregnancy and can be associated with pre-eclampsia. Pre-eclampsia is a condition which causes high blood pressure and excess protein in the urine. It also causes swelling in the hands, feet and face, and headaches. Pre-eclampsia can progress to eclampsia which causes seizures and can be life-threatening for the mother and baby if untreated.

22. A venus sinus thrombosis or VST is a blood clot which occurs in the large veins in the brain which drain blood. Symptoms include headaches, seizures and blurred vision which can also progress to brain swelling or haemorrhage. A CT scan with intravenous dye is used to highlight the veins providing high resolution images to enable detection of clots.

23. Women have a higher risk of developing blood clots including VST’s throughout pregnancy, child birth and even after giving birth. Blood clots are dangerous as they can block blood flow to important organs in the body.

24. Mrs K first reported she had been having headaches at 19 weeks. She discussed headaches at her antenatal appointment at 20 weeks with her records stating she did not require pain relief. Mrs K reported a headache during an antenatal appointment at 25 weeks, with her records noting she did not require pain relief.

25. Mrs K then reported a frontal headache on her admission in November at 32 weeks pregnant and clinicians prescribed codeine. Her headaches increased on day 2 of her admission and on day 3 she received further codeine. On day 4 clinicians offered Oramorph medication as Mrs K reported sickness with the codeine. Clinicians also discussed with Mrs K the risks of blood clotting and her family history of this.

26. Neurology clinicians also reviewed Mrs K and considered that a VST was clinically unlikely but should still be investigated. Mrs K underwent a CT scan later that day with the report confirming a right sigmoid sinus thrombosis which is a formation of a blood clot in the venous channel on the right side of the brain.

27. We sought clinical advice to help us understand Mrs K’s situation. Our obstetrics adviser said the three-day period to diagnose Mrs K with a VST was not unreasonable in view of her pre-eclampsia diagnosis. Clinicians referred Mrs K for further investigations within three days of her November admission when she reported headaches.

28. Clinicians assessed Mrs K on admission to be at an intermediate risk of blood clots with her pre-eclampsia and raised BMI. They started low molecular weight heparin (LMWH) anti-clotting treatment in line with RCOG guidance mentioned earlier.

29. Our obstetrics adviser said Mrs K’s pre-eclampsia would have made a VST diagnosis difficult. She also took nifedipine medication to manage her blood pressure which is known to cause headaches. VST is a rare condition which can be difficult to diagnose in pregnancy as the symptoms tend to be non-specific. A neurology specialist had also assessed Mrs K and considered a VST unlikely.

30. We recognise Mrs K’s frustration that she felt she had to push for clinicians to take her headaches seriously. We cannot say Mrs K’s VST should have been diagnosed sooner as her headaches could have been attributable to pre-eclampsia or side-effects of her nifedipine medication.

31. There is no indication of a failing here and we will take no further action.

Hypoglycaemia

32. JBDS-IP guidance on hypoglycaemia say that patients with a blood glucose concentration of less than 4mmol/L should be treated with a fasting acting carbohydrate by mouth. It recommends treatment is repeated after 15 minutes up to a maximum of three treatments in total.

33. Mrs K complains clinicians appeared unfamiliar in dealing with hypoglycaemia and she had to provide instructions when she regained consciousness. She says clinicians did not monitor her appropriately after her hypoglycaemic episode and she received no food or drink for 24 hours which made managing her medication and mealtimes difficult. Mrs K also considers the hypoglycaemic episode occurred because staff did not administer her morning insulin.

34. The Trust said clinicians monitored Mrs K appropriately following her hypoglycaemic episode and provided her with glucose, in line with national guidance. It said the diabetic nurse had given Mrs K advice to increase her Humulin insulin in the morning which she should self-administer. The Trust said it was extremely disappointed Mrs K was not offered adequate refreshments and that this fell below the expected standard of care. It said the birth centre now had a new menu in place which was suitable for diabetic pregnant women.

35. Diabetes is a condition where the body does not make enough insulin or the insulin does not work correctly. Insulin is an essential hormone which helps the body use glucose for energy. Symptoms of diabetes include increased thirst, fatigue, increased urinary frequency and weight loss.

36. Type 1 diabetes is an autoimmune condition which commonly starts in children and requires daily insulin to keep blood glucose levels within safe parameters. This type of diabetes cannot be prevented. Type 2 diabetes is also a deficiency in insulin which can be managed with diet, exercise and medication. Pregnant women can also develop diabetes during pregnancy which is known as gestational diabetes and tends to disappear following birth.

37. Hypoglycaemia is a condition where the blood sugar levels drop. Symptoms can include an increased heart rate, anxiety, confusion, fatigue, dizziness and aggressive behaviour which if untreated can lead to fainting and or seizures. JBDIS-IP guidance recommends providing patients with biscuits when their glucose levels return to 4 mmol/L.

38. Mrs K had type 2 diabetes and clinicians planned a review from the diabetic team on her November admission due to concerns over her raised blood sugar levels. Mrs K spoke to her diabetic nurse around 10am the following day who advised her to self-administer 12 units of Humulin that morning.

39. Around six hours later nursing staff responded to Mrs K’s call bell and noted she struggled to speak and looked unwell. Staff recorded her blood glucose level at 2.2mmol/L – this was below the safe 4 mmol/L threshold.

40. Mrs K received a glucose shot and staff tested her glucose levels which rose to 2.7 mmol/L/l. She received another glucose shot and a further blood test said her glucose level was 3.6 mmol/L/l. Staff administered another glucose shot and her glucose level rose be 4 mmol/L/l.

41. Mrs K reported feeling slightly better within an hour of the hypoglycaemic episode and her records say she was alert and sat upright. Staff provided Mrs K with biscuits when her glucose returned to a safe level, in line with JBDS-IP guidance mentioned earlier.

42. Mrs K is concerned staff did not administer her insulin medication that morning. Her records show the diabetic nurse told Mrs K on the morning of her hypoglycaemic episode what insulin she should take and for her to self-administer this. Mrs K’s records also confirm she self-administered her insulin medication around three hours after the request which the diabetic nurse considered led to her hypoglycaemic episode.

43. Our midwife adviser said nursing staff monitored Mrs K appropriately following her hypoglycaemic episode. Mrs K received three glucose treatments in line with JBDS-IP guidance, and thankfully she recovered within an hour.

44. There are no records which show Mrs K had to tell staff what to do following her hypoglycaemic episode and we are not doubting her account of this. The lack of documentary evidence means we cannot take a view on this. We hope Mrs K is reassured that staff did all they should have done and in line with guidance to manage her hypoglycaemic episode.

45. Mrs K received support from the diabetic team at the Trust, she had an assigned diabetic nurse and clinicians supported her with nutritional and diet information before and during her pregnancy. Our midwife adviser said Mrs K was not considered to be nutritionally vulnerable and that she would not have required additional monitoring for her dietary needs.

46. Mrs K’s records show following the hypoglycaemic episode she did not eat a lot at dinner, and she later asked for toast which staff provided. Mrs K asked for toast the following morning with her records noting she wanted to get her blood glucose under control. In the afternoon it appears Mrs K missed lunch and staff apologised and provided her with a sandwich.

47. Our midwife adviser said a typical menu would have suitable things for Mrs K to eat and that a specialist diabetic menu would not have been necessary. Our midwife adviser also said Mrs K had been diagnosed with type 2 diabetes several years earlier and that she had knowledge of her condition and how to manage her diet and glucose levels. This is supported by Mrs K’s records which confirm she could adjust her insulin doses if required.

48. The evidence we have seen suggests clinicians monitored Mrs K regularly in line with JBDS-IP guidance mentioned earlier. She also received food and drink within 24 hours of the hypoglycaemic episode.

49. There is no indication of a failing here and we will take no further action.

Advice

50. NG3 guidelines recommend women with insulin-treated diabetes are given additional insulin according to an agreed protocol and are monitored appropriately.

51. Mrs K complains clinicians gave her incorrect medication information when it became clear she would be having an early birth. She says clinicians told her to stop fast-acting insulin before meals and to continue long-acting insulin doses in the morning and evening. Mrs K says this miscommunication caused her distress and uncertainty.

52. The Trust said clinicians discussed with Mrs K about taking steroids to help her baby’s lungs mature. It said steroids could increase her blood sugar levels and she was started on an insulin sliding scale and advised to stop fast-acting insulin before meals and to continue with her long-lasting insulin. The Trust apologised and confirmed the advice given to Mrs K was incorrect and that the staff member involved had been made more familiar with the diabetic policy on a general ward.

53. A consultant reviewed Mrs K at 33 weeks and discussed the need for steroids due to her baby’s delivery date being brought forward. Her insulin management plan involved dropping to pre-pregnancy dosage which the records note is a significant drop. The diabetes nurse advised Mrs K she may need to increase the dose if her blood glucose drops below 12mmol/L.

54. Mrs K commenced a sliding scale insulin protocol which involved having her blood glucose monitored every one to two hours so that clinicians could see her glucose levels at any given time. A sliding scale provides flexibility to manage spikes in blood sugar which could be caused by the steroid she was taking. Fast acting glucose lowers blood glucose levels when necessary.

55. Clinicians monitored Mrs K’s blood glucose levels and noted they did not appear to be stabilising. Two days later Mrs K confirmed to staff she had continued to take fast-acting insulin since starting the sliding scale protocol. Clinicians suggested this could explain her unstable glucose levels. Clinicians stopped the sliding scale protocol and told Mrs K to resume her normal insulin regime.

56. Our midwife adviser said Mrs K had been well supported with her diabetes throughout her pregnancy. This is evidenced by interactions with the diabetic team before Mrs K got pregnant. The Trust also assigned Mrs Ka diabetic nurse during her pregnancy who assisted her in monitoring blood sugar and her insulin dosage, in line with NG3 guidelines. Blood glucose management and food intake are very much linked, and our midwife adviser said Mrs K was responsible for self-managing her condition.

57. We acknowledge Mrs K’s frustration at receiving the incorrect advice and the additional worry this caused her during her pregnancy. The Trust has apologised for giving Mrs K the incorrect advice stating the staff member involved had been unfamiliar with the protocol for pregnant women with diabetes.

58. We also note from Mrs K’s records she did not act upon the clinician’s advice to stop taking fast acting insulin. We cannot say there was a clinical impact here and there is nothing further we could achieve by investigating this further.

59. There is no unremedied injustice here and we will take no further action.

Sterilisation

60. RCOG guidance on female sterilisation states that tubal occlusion (permanent contraception which prevents pregnancy by blocking the fallopian tubes) should be requested at an appropriate level after pregnancy where possible. The guidance states several studies have reported increased incidences of regret and dissatisfaction when sterilisation has been performed at the same time as a caesarean section procedure.

61. Mrs K complains a clinician pushed her for sterilisation in the week before her son’s birth while she was alone without her husband and in a poor mental state due to her long in-patient stay. She says she found this unprofessional and it caused her further distress after she had already experienced a difficult time as an inpatient.

62. The Trust said that sterilisation is not usually discussed but in high-risk pregnancies, clinicians have a responsibility to ensure patients are aware of all the options. It said where a future pregnancy would put a mother at significant risk of death or serious injury/illness, the discussion would be appropriate. The Trust apologised this was not held in a more supportive and empathetic manner and agreed the timing of the discussion was inappropriate.

63. There are no records of the sterilisation conversation between Mrs K and the clinician which means we cannot know exactly what was said. The conversation clearly caused Mrs K distress which the Trust has acknowledged.

64. Our obstetrics adviser noted Mrs L had significant health risks at the time of her pregnancy including her Type 2 diabetes, hypertension, history of thrombosis and a high BMI which placed at risk for a future pregnancy.

65. Our obstetrics adviser said it was not appropriate for clinicians to recommend permanent loss of fertility. There are several, reversible and effective contraception options available which Mrs K could have selected if she wanted to delay or decide against another pregnancy.

66. There are certain circumstances where sterilisation at the time of a caesarean section is appropriate. Our obstetrics adviser said Mrs K’s age and the fact this was her first child meant there would be an increased risk of regret and that sterilisation should be discouraged.

67. FSRH guidelines say that women should be informed during pregnancy about the effectiveness of different contraception. As stated previously, we do not know exactly what was said. We consider it was correct for the issue of contraception to be raised in view of Mrs K’s increased risk factors and sterilisation is one method of contraception.

68. It would not have been appropriate for the clinician to discuss sterilisation or put any pressure on Mrs K especially as she told us at the time she was feeling extremely upset and vulnerable without her husband present.

69. The Trust has accepted and apologised for this, and it has reflected the timing of the conversation was inappropriate. We undertake precedent checks as part of our investigation process to identify trends and similar complaint type. We are satisfied there is no systemic issue here.

70. There is no unremedied injustice here and we will take no further action.

Stitches

71. Our principles for remedy say that organisations should promptly identify and acknowledge maladministration and poor service and apologise for them. The principles state an apology means acknowledging the failure and explaining clearly why it happened.

72. Mrs K complains she was wrongly told by clinicians that her stitches were dissolvable. She says they should have been removed five-days after her caesarean section. She says a midwife visited her at home and tried to remove them and the pain was unbearable. Mrs K says she got an infection because the stitches were in longer.

73. The Trust acknowledged Mrs K’s prolene stitches should have been removed 5 – 7 days after her caesarean section and it apologised this did not happen. It said it would be developing a patient information leaflet for all women who had caesarean sections explaining suture methods. The Trust also said the delay in the removal of Mrs K’s stitches would not have resulted in an infection.

74. Prolene stitches are commonly used to close caesarean incisions as they are naturally resistant to infections and can prevent blood clots. They are typically removed 7 – 10 days following the procedure with the removal time varying according to the patient’s healing time.

75. Mrs K had a PICO dressing on her caesarean incision site. A PICO dressing provides controlled suction to heal surgical wounds reducing the risk infections by promoting blood flow to the area and removing excess fluid.

76. Clinicians recorded Mrs K’s stitches as dissolvable on day 2 following her caesarean section noting slight oozing on the dressing which was not a concern. On day 5 clinicians discussed registering Mrs K’s son’s birth and planned to remove her PICO dressing and her stitches the following day.

77. Clinicians removed Mrs K’s PICO dressing on day 7 with her wound assessed to be healing well, clean and dry. Mrs K also received advice on the signs and symptoms of infections to look out for. She also received a wellbeing call on day 10 and she reported the wound to be healing well with no signs of infection.

78. A midwife visited Mrs K on day 11 which was also her son’s first day at home following his discharge from the NNU. Mrs K did not report any pain, and the midwife assessed the caesarean wound to be healing well with no signs of infection. The midwife noted the presence of moisture and gave Mrs K advice on keeping the wound disinfected and when to escalate any concerns.

79. The records show following this visit the midwife returned to base and identified Mrs K had prolene stitches which should have been removed by day 7. The midwife contacted Mrs K to apologise and made an appointment for her the following day to remove her stitches.

80. Mrs K attended hospital on day 12 to get her stitches removed. She reported feeling unwell, being in a lot of pain and clinicians noted her wound was red, inflamed and leaking fluid which was suggestive of infection. Clinicians referred Mrs K for obstetric review.

81. Clinicians removed the prolene stitches that evening which they noted to be difficult due to the skin healing over the sutures and gave her Entonox (gas and air) to assist with the removal. Mrs K remained in hospital for 5 days to treat the infected wound. Senior staff visited her on the ward to apologise for the delay in removing the stitches.

82. Our obstetrics adviser said there is no increased risk of infection with the delayed removal of non-absorbable stitches and that the main risk is that they become difficult to remove. Our obstetrics adviser said Mrs K’s BMI would have placed her at considerable risk of wound infection.

83. We acknowledge it was difficult for Mrs K to be readmitted to hospital when her son had only just been discharged from the neonatal unit. We cannot say Mrs K’s stitches being left in longer led to her infection and we also note she did not report any pain until day 12 when she attended hospital to get the stitches removed.

84. We hope Mrs K is reassured that her stitches being left in longer was not the reason for her infection. We are pleased the Trust acknowledged the error with her stitches, senior management apologised to her in person and in the complaint response which is line with our principles for remedy mentioned earlier.

85. There is no unremedied injustice here and we will take no further action.

86. We acknowledge Mrs K went through a challenging and distressing experience before and after the birth of her son. We hope she is reassured by our investigation of your complaint.

1. We are sorry for the circumstances that have led Mrs K to bring her concerns to us. We acknowledge her distress and anxiety and concerns about her treatment before the birth of her son and her subsequent aftercare. We recognise the effect on her and that this impacted her ability to fully enjoy the birth of her first child.

2. We have carefully considered Mrs K’s complaint about Chesterfield Royal Hospital NHS Foundation Trust. On the matter of her blood clot diagnosis and the aftercare following her hypoglycaemic episode we have found no indication that anything went seriously wrong.

3. We consider Mrs K’s concerns about insulin treatment information, sterilisation discussions and the removal of caesarean stitches, have already been put right by the Trust.

4. Our statement below explains the reasons why.