Barking, Havering and Redbridge University Hospitals NHS Trust

5. Miss R complains about the antenatal care Barking, Havering and Redbridge University Hospitals NHS Trust (the Trust) provided between January and March 2023. Specifically, that the Trust:

• did not inform her about the diagnosis of foetal growth restriction, and she was told about this by the bereavement team • missed several opportunities to provide her with crucial information on foetal growth restriction, what this meant for her baby, and the risks to her • community midwife failed to monitor her pregnancy every two weeks as stated by the consultant, and they did not listen to her concerns that she was high risk.

6. Miss R also complains about the Trust’s complaint handling, she says it did not properly log her complaint, delayed replying to her, and its response failed to address all her concerns.

7. On 3 March 2023, Miss R’s daughter was stillborn. Miss R says the lack of action and communication by the Trust, resulted in the unexpected death of her baby.

8. Miss R says the lack of information from the Trust put her in a vulnerable position, and she was unable to act accordingly, unable to protect herself or her baby, or prepare for her baby’s passing which has had a significant impact on her.

9. Miss R experienced physical and emotional trauma. She has diagnosed PTSD, flashbacks and panic attacks. Miss R is having counselling, and she has been unable to return to work.

10. Miss R says the lack of concern the Trust showed for her and her daughter has caused significant anxiety. She feels the Trust was not listening to her concerns, and the way the Trust handled her complaint has exacerbated her grief. Miss R describes a loss of trust in the NHS and the medical professionals in charge of her care.

11. Miss R is seeking an acknowledgement of the mistakes the Trust made, service improvements and a financial remedy as an outcome to the complaint.

12. On 28 November 2022, Miss R attended an antenatal appointment. She was taking aspirin and having growth scans due to borderline hypertension (high blood pressure) and a family history of pre-eclampsia (a condition in pregnancy that causes high blood pressure).

13. Miss R had her first trimester ultrasound scan on 30 November.

14. On 3 January 2023, Miss R attended an antenatal review. A consultant review was arranged.

15. Miss R had a further antenatal appointment on 16 January. Genotyping (analysis of DNA) was discussed and Miss R was given an information leaflet about this.

16. A 20-week anomaly scan on 20 January found no abnormalities but an impaired uterine artery blood flow. This occurs when the blood vessels supplying the uterus experience high vascular resistance. Notching on both sides was identified.

17. Miss R attended a follow-up appointment with a consultant, and a midwife antenatal clinic.

18. At an antenatal review on 24 January, the Trust recorded Miss R's blood pressure as high. It planned to check her blood pressure in two weeks’ time.

19. At an antenatal review on 2 February, Miss R reported headaches at times but no visual disturbances.

20. Miss R attended a 24-week glucose tolerance test (GTT) test appointment on 20 February.

21. A further antenatal check was carried out on 1 March. Midwives discussed the importance of reduced foetal movements and Miss R was shown a leaflet. The midwife was unable to find a foetal heartbeat and they asked Miss R go to hospital where it was sadly confirmed that there was no foetal heartbeat. That must have been incredibly difficult for Miss R. Miss R was admitted to hospital, and a doctor gave her mifepristone to induce labour.

22. Miss R delivered her stillborn daughter on 3 March and a post-mortem was carried out on 8 March.​

Management of early pregnancy

25. The first parts of Miss R’s complaint all relate to the Trust’s management of her in early pregnancy. We have considered these elements together.

26. Miss R says she was not properly monitored during her pregnancy despite being highrisk, and that she should have had consultant-led care. She says the Trust should have explained the risks associated with foetal growth restriction and it did not do so until she sadly lost her daughter.

27. Guidance from the Royal College of Obstetricians and Gynaecologists on the investigation and management of foetuses of small gestational age contains an algorithm for risk assessing women for foetal growth restriction.

28. Three or more minor risk factors or one major risk factor should prompt a reassessment at 20 weeks gestation. Minor risk factors include a maternal age over 35 years old, a BMI less than 20, and a BMI between 25 and 34.9.

29. Major risk factors include chronic hypertension (high blood pressure).

30. Miss R had two minor risk factors. One was her age: she was over 35 at the time of the events. The second was her body mass index (BMI). This was 31. She also had one major risk factor, hypertension (high blood pressure). This was borderline.

31. NICE guidance on the management of hypertension in pregnancy says:

‘Advise pregnant women at high risk of pre-eclampsia to take 75 mg to 150 mg of aspirin daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following:

• hypertensive disease during a previous pregnancy • chronic kidney disease • autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome • type 1 or type 2 diabetes • chronic hypertension.

Advise pregnant women with more than 1 moderate risk factor for pre-eclampsia to take 75 mg to 150 mg of aspirin daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are: • nulliparity • age 40 years or older • pregnancy interval of more than 10 years • body mass index (BMI) of 35 kg/m2 or more at first visit • family history of pre-eclampsia • multi-foetal pregnancy.’

32. Miss R was already taking aspirin from early in the pregnancy, to reduce her risk of preeclampsia. She did not fulfil the diagnosis of chronic hypertension but had other risk factors for pre-eclampsia. This was her first pregnancy, she had an elevated BMI, and she was nearly 40 years old. It was therefore reasonable for her to take aspirin.

33. The Trust did reassess Miss R at 20 weeks as per the Royal College guidance. The risk factors for foetal growth restriction led the Trust to perform an ultrasound measurement of uterine artery doppler flow at 20 weeks’ gestation.

34. This result had some abnormalities which led to an automatic recommendation for serial scanning for foetal growth from 26 to 28 weeks’ gestation as noted in Miss R’s records at an antenatal clinic visit on 24 January 2023. Further scanning was scheduled at 28, 32 and 36 week’s gestation.

35. NHSE guidance on saving babies’ lives contains guidance on what to do if a scan at 20 week’s gestation shows an unexpectedly small baby (or an estimated foetal weight – EFW – below the 10th centile. The 10th centile means a baby’s estimated weight or size is smaller than 90% of babies at the same stage of pregnancy). It recommends for referral to a foetal medicine specialist if a scan confirms a EFW below the 10th centile.

36. The growth scan carried out at 20 weeks specifically notes the growth of Miss R’s baby was normal. A foetal medicine referral was therefore, not required at this stage.

37. The Trust did not diagnose growth restriction during the pregnancy, and the examinations it carried out did not suggest growth restriction. This diagnosis was made retrospectively from weighing the baby after delivery and reported on the post-mortem.

38. This indicates that the significant slowdown in growth associated with the stillbirth occurred between 20 weeks (when the scan indicated normal growth) and 25 weeks 5 days (when Miss R sadly had a stillbirth).

39. Our adviser says such early growth restriction is associated with a very poor prognosis for the baby. Even if this had been picked up on scanning between 20 and 25 weeks (and scanning was not indicated during that time) no treatment could have been given to improve the growth, and delivery during this part of the pregnancy would be associated with a high risk of neonatal death from complication of prematurity.

40. Miss R says the Trust did not give her crucial information on foetal growth restriction, what this meant for her baby, and the risks to her.

41. The Trust identified growth restriction was a risk due to Miss R’s various risk factors and the notching on the uterine artery doppler at the 20-week scan.

42. But our adviser confirms there was no diagnosis of growth restriction during the pregnancy. It was therefore not necessary for the Trust to discuss this condition or the risks associated with this with Miss R.

43. We asked our adviser if a consultant advised midwives to check Miss R every fortnight during the pregnancy. Our adviser says a senior obstetric registrar who saw Miss R on 24 January asked for a blood pressure (BP) repeat after two weeks by a community midwife.

44. This check was not for growth restriction, but to ensure her BP was stable. Miss R’s BP was checked on 2 February and was normal. Our adviser says there was no need for a further urgent check to take place.

45. We recognise the impact the events had and continue to have on Miss R. We understand how upsetting the events continue to be for Miss R and how devasting the loss of her baby has been.

46. We have found the Trust’s management of Miss R’s early pregnancy, despite the risk factors she had, was in line with national guidance. The Trust followed the recommended pathways and national guidance for the risk assessment and surveillance of possible growth restriction and it acted correctly in screening and its surveillance recommendations.

Complaint handling

47. Miss R says the Trust did not properly log her complaint, delayed replying to her, and its response failed to address all her concerns.

48. 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.’

49. 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 and should provide regular updates throughout.

50. The Trust’s complaints policy outlines that on receipt of a complaint, including via its patient advice and liaison service (PALS) team, the complaint should be acknowledged centrally before being passed to a complaint coordinator in the division the complaint is about.

51. On 10 March 2023, Miss R spoke with a midwife on the telephone to discuss her concerns about the care she received.

52. Miss R says her complaint was not logged properly following this call when she discussed her concerns about the care she had received from the Trust. There is no dispute that a call took place. It is unclear from the evidence whether the Trust considered this call was a complaint from Miss R. The Trust’s response dated 24 August says that following the call it sent a summary of the discussion to Miss R for review and advised her to amend where necessary and send this onto the Trust’s complaints team for an investigation.

53. Due to the differences in accounts about how the complaint should be progressed following the call, we are unable to reach an independent view as to what Miss R was told about raising a complaint. We cannot say the Trust failed to act in line with its own complaints policy when not logging it at this point.

54. That said, the Trust has implemented a service improvement following Miss R’s complaint. It says if a concern is raised by a mother it must be clearly identified how she would like the concern responded to, for example via PALS or via the Trust’s formal complaints route, and this must be agreed with the mother. We are encouraged the Trust has put an improvement in place to prevent further concerns or complaints about the way in which these should be logged. We consider this is enough to prevent a recurrence.

55. Miss R raised a formal complaint with the Trust’s PALS team on 10 April 2023. PALS acknowledged the complaint on 11 April and sent it to the complaints team the same day. That was in line with its complaints policy.

56. Miss R sent a further email to PALS on 14 April, with an updated complaint.

57. A local resolution meeting was scheduled to take place on 6 June. Miss R emailed the complaints coordinator for the division after attending the meeting expressing her disappointment that the meeting had not been as planned as staff were not prepared for it. She asked to rearrange the meeting for another date. Miss R wanted the Trust to finish its investigation before a further meeting.

58. The complaints coordinator responded on 8 June. They apologised the meeting did not go as planned and said it was necessary to reschedule. They said the Trust would ensure all of Miss R’s questions were answered and a response given prior to the meeting now scheduled for 25 July.

59. Miss R sent an email on 8 June with questions she wanted a response to. The complaints coordinator emailed Miss R on 9 June and said her questions would be responded to as part of the Trust’s investigation.

60. Miss R sent the Trust more concerns she wanted to be added to her complaint on 17 June. The Trust acknowledged Miss R’s email on 20 June and sent her concerns to the investigating officers.

61. Miss R contacted the Trust on 16 July asking for a copy of the complaint outcome following the first local resolution meeting to read through before attending the next meeting.

62. The Trust acknowledged Miss R’s email on 18 July. The Trust said an investigation was ongoing. They said the consultant involved had been off sick and had returned to work that week. They said staff were liaising with the team and would send Mrs R an update on Thursday 20 July.

63. An internal email sent on 21 July from the lead bereavement midwife (LBM) noted Miss R had sent a text on 20 July asking for the next meeting to be cancelled and, instead, requested all responses to be sent in the post/via email. The email noted Miss R had also requested a date for a written response. A quality manager said they would confirm a date the following week once they had met with the complaint coordinator and the Trust’s new consultant obstetrician who would help answer some of Miss R’s concerns.

64. Miss R sent the complaint coordinator an email on 21 July. She said she had emailed the previous week and was due an update on 20 July. She said that due to an update not being received, she was unable to prepare for the scheduled meeting on 25 July as she did not have a copy of the outcome to her complaint.

65. Miss R sent a message to the LBM about a response. It is not clear what date this was sent to the LBM as there is no evidence of this contact. We have assumed this was sent to the LBM via a text message due to previous contact via this method with this member of staff. On 16 August, the LBM sent an email to the staff involved informing them of Miss R’s contact. The Trust sent Miss R an update the same day. It said it was working to the extension it previously agreed with Miss R, of 22 August.

66. The Trust sent Miss R a further update on 21 August. It said its response was with its executive team for sign-off and a member of staff would email Miss R if and when approved in addition to posting it.

67. The Trust response is dated 24 August. One of the actions noted on the response was for the Trust to contact Miss R and offer her a debrief meeting with a consultant midwife.

68. On 29 August, Miss R contacted the complaint coordinator copying in other members of staff involved in investigating the complaint and received an automated outofoffice reply. She emailed again and said she felt everyone was on leave to put her complaint to one side. A Trust maternity and quality safety manager emailed Miss R the same day and advised this was not the case and asked if she received the Trust’s response dated 24 August.

69. On 30 August, the Trust apologised as it assumed the complaint response had been sent to Miss R the previous week. It said the response had been approved and would be sent to Miss R in the post and via email.

70. On 1 September 2023, the Trust told Miss R it could not keep adding additional concerns to the complaint during an ongoing investigation in response to an email noting her concerns about outstanding concerns being missed. The Trust said its intention was to arrange a debrief meeting with midwifery and obstetric leads to ensure Miss R’s concerns were answered. This was scheduled to take place week commencing 25 September after Miss R had spent some time reviewing the Trust’s response.

71. The Trust issued its final response dated 26 October. It noted Miss R’s emails to the Trust dated 29 September and 12 October. We assume the final response was in response to those emails, but we have not seen the content of these emails as they were not included in the complaint file.

72. The response noted the Trust had offered another meeting which was declined by Miss R. It said that on review of her further correspondence, it had nothing further to add to what it had already said.

73. Given the sensitive nature of this complaint and Miss R’s concerns, it is understandable she felt the Trust had not considered her concerns.

74. When Miss R raised a formal complaint on 10 April, the complaint was swiftly passed to the complaints team by PALS.

75. In line with the Trust’s complaints policy, the complaint was passed on to the relevant division to progress. The division’s complaint coordinator contacted Miss R and a meeting was arranged to take place on 6 June. This did not go as planned and a second meeting was scheduled for 25 July.

76. Miss R continued to contact the complaint coordinator with outstanding concerns to be discussed at the next meeting. She asked for a copy of the complaint outcome following the first meeting to read through before attending the next meeting.

77. We have seen no evidence of a further update until 16 August although we note from the Trust’s email on this date and its response dated 24 August, that an extension was approved by Miss R to enable a written response. The complaint coordinator advised they would email Miss R once its response dated 24 August was approved before posting it. We have seen no evidence of contact with Miss R about the response on this date.

78. The Trust’s response dated 24 August acknowledged the time it had taken to respond to the complaint. It apologised for the delay in responding. The Trust sent a final response dated 26 October after a review of additional emails from Miss R on 29 September and 12 October. It said it was unable to add anything further to what it had already responded to.

79. We recognise Miss R’s view that the Trust did not answer her concerns and we acknowledge the events were and continue to be incredibly distressing for her. Our view is the Trust did take account of Miss R’s core 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 pregnancy.

80. The Trust answered and acknowledged the core aspects of the complaint and scheduled a follow up debrief meeting to ensure all of Miss R’s concerns were responded to. We acknowledge additional concerns may have been raised similar to those noted in her initial correspondence and subsequent communications with the Trust, but we would not expect an organisation to respond again. We do not consider the Trust was dismissive of her concerns. It acted in line with our NHS Complaints Standards.

81. We have not identified any significant delays in the handling of Miss Rs’s complaint. Miss R raised a formal complaint in April and the Trust responded to this after Miss R requested a written response during the process, in August, four months after receipt of her complaint.

82. That said, the Trust’s communication did not always adhere to the NHS complaints standards, particularly around updating Miss R about what was happening. We consider the Trust could have communicated the difficulties it was experiencing in sending Miss R a copy of the complaint outcome sooner than 18 July, which was very close to the second meeting scheduled for 25 July. The Trust knew Miss R was keen to know the outcome before the meeting. This was the reason why she cancelled the July meeting and opted for a written response instead. Given the sensitive nature of the complaint, we consider it was appropriate for Miss R to have been given some time to prepare for the next meeting with information she needed.

83. We have seen no evidence of contact with Miss R on 20 July as noted in an email on 18 July when a complaint coordinator said they would send another update. This led to Miss R contacting the LBM on 20 July and the complaint coordinator on 21 July.

84. We have seen no evidence of contact with Miss R until another update was sent to her on 16 August following her contact with the LBM. We acknowledge this update was sent nearly a month after the Trust’s contact with Miss R on 18 July. However, this left Miss R without an estimated time for a response or further update and we have seen no evidence of an extension being approved as noted by the Trust.

85. The complaint coordinator said they would also email Miss R once the Trust’s response dated 24 August was approved before posting it. We have seen no evidence of contact with Miss R about the response on this date. If the Trust sent an update on 24 August, this may have prevented further contact from Miss R, leading to the complaint response being sent on 30 August once it was approved to be shared.

86. The lack of updates between July and August when Miss R was expecting them caused her upset and distress at an already, difficult time given how soon after it was after her baby’s stillbirth.

1. We are very sorry to hear about the loss of Miss R’s daughter. We recognise this was a deeply distressing and traumatic experience for Miss R, and that the events around her pregnancy, her daughter’s stillbirth, and the later complaint process have had a significant and lasting impact on her.

2. Miss R says she was not properly monitored during her pregnancy despite being high-risk, and that she should have had consultant-led care. She feels the Trust should have explained the risks associated with foetal growth restriction and it did not do so until she sadly lost her daughter.

3. We found the Trust’s management of Miss R’s pregnancy was in line with relevant guidance. The Trust monitored her appropriately during her early pregnancy despite some risks associated with the pregnancy. There was no diagnosis of growth restriction during the pregnancy and therefore the Trust did not need to discuss this with Miss R.

4. We found the Trust handled Miss R’s complaint correctly on receipt of it in April 2023 and it addressed her concerns. We have not found any significant delays in the handling of the complaint. But the Trust did not send Miss R some updates between July and August 2023. We consider this caused Miss R distress at an already difficult time given how soon it was after the stillbirth of her baby. We consider the Trust should apologise and pay Miss R £200 to remedy the distress she experienced.

87. 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.

88. 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.

89. Through investigating this complaint, we found:

• A lack of some updates, some at the times the Trust said it would update Miss R led to her to chase the Trust. We consider the failings in communication caused Miss R some distress, at an already difficult time.

90. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

91. The Trust should write to the Miss R to:

• acknowledge that during the complaint process it did not always keep her updated in a timely way • apologise for the distress this caused Miss R so soon after the stillbirth of her baby • send a copy of this letter to us within four weeks of the date of our final report.

92. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend the Trust:

• pay Miss R £200 in recognition of the distress she experienced due to a lack of some updates during the Trust’s complaints process between July and August.

• send us evidence it has done this within four weeks of the date of our final report.

93. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.

94. With that in mind, we recommend that following this final report the Trust:

• produces an action plan to address the failings relating to sending complainants updates, especially when complaints coordinators have advised updates are due.

• identify the reason(s) for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is/was responsible, timescale for completion, and how it will be/was monitored • share the action plan with us and Miss R by within six weeks of the date of our final report.

95. The Trust should send us evidence it has completed all of the recommendations we have made. We will check the action plan includes the reason for the failing (where possible), what the organisation does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.

96. We recognise that no investigation or remedy can change what happened or remove the distress Miss R has experienced. We hope this report gives her a clear explanation of how we have considered her concerns and how we reached our decision. We also hope the steps we have recommended will help acknowledge the additional distress caused by the Trust’s communication failings at an already very difficult time.

97. This concludes our final report.