A practice in the Cambridge area

6. Miss B complains about the actions of a Practice in the Cambridgeshire area. Specifically, the Practice: • improperly shared untrue IVF related information to social services without her consent in 2025 • prescribed a medication with the incorrect dosage on 15 April 2025 • failed to inform her that the prescribed medication, Labetalol, would affect her son’s blood sugar levels.

7. Miss B says the Practice sharing incorrect information to social services without her consent and prescribing her the incorrect medication dosage caused her significant distress, contributed to the escalation of her PTSD symptoms and caused her to lose trust in the professionals involved in her care.

8. She says the Practice’s failure to inform her about the effects of the medication led to her son experiencing blood sugar instability after birth, which required hospital monitoring for 8–9 days. This disrupted the immediate postnatal period, hindered early bonding, and made it challenging for her to start breastfeeding. She also says the medication caused her to develop a wheezy cough.

9. She says had the Practice informed her about the potential effects of the medication, she would have been able to make a more informed decision about taking it. She also says the Practice actions affected her ability to engage with healthcare services and affected her wellbeing during her pregnancy.

10. As an outcome of her complaint, Miss B would like the Practice to acknowledge their wrongdoing, an apology and service improvements.

11. Between 2023 and 2024 Miss B approached a fertility service with the desire to get pregnant through In Vitro Fertilisation (IVF).

12. The fertility clinic contacted the Practice in October 2023 to inform them Miss B was considering IVF. The Practice corresponded with the fertility clinic.

13. On 9 January 2025, Miss B’s midwife informed the Practice Miss B had been booked for maternity care. On 8 January a midwife informed the Practice Miss B had high blood pressure. The Practice prescribed her the blood pressure medication labetalol.

14. On 27 March 2025, the Multi-Agency Safeguarding Hub for Child and Family (MASH C&F) asked the Practice for information about Miss B’s mental health, wellbeing and fertility services information. The Practice shared information with MASH C&F.

15. We reviewed her records and sought clarification from the Practice about how they managed Miss B’s blood pressure. The Practice increased her medication in February, March and April.

Sharing Untrue IVF Information

19. Miss B complains the Practice shared incorrect information regarding her IVF planning without her knowledge. She says the information was shared to social services without her consent.

20. Records show in 2023/2024 Miss B considered In Vitro Fertilisation (IVF) and she approached a fertility clinic.

21. The fertility clinic contacted the Practice in October 2023 to inform it Miss B was considering IVF. It requested information to support an assessment of the welfare of the unborn child. The clinic specifically asked for details regarding any mental health, medical, or social concerns. It stated it was aware of Miss B’s diagnoses of ADHD, Autism and PTSD, as well as her use of antidepressants, but sought further clarification on these matters.

22. In March 2024, the Practice responded to the fertility clinic by providing details of her medical history. The Practice informed the clinic she had been struggling with her mental health since her teenage years. It noted she was on the waiting list for Choice Counselling and highlighted her consistent engagement with services following referrals, as well as her efforts to improve her mental health. The Practice also provided information about the antidepressant it prescribed her.

23. In June 2024, the fertility clinic acknowledged the information clarifying Miss B's mental health history and it requested additional details regarding her hypertension (high blood pressure) diagnosis and the ACE inhibitors she had been prescribed. It also enquired whether she had any new mental health concerns or required additional psychological support.

24. The Practice responded in July 2024 by providing the requested information about her blood pressure. It also noted, given her PTSD, autism and ADHD diagnoses, a safeguarding referral would need to be made if she became pregnant to ensure she received the appropriate support.

25. The records do not state the final outcome/ decision regarding the IVF process.

26. On 9 January 2025, the Practice received a request from Miss B’s midwife. They informed the Practice Miss B had been booked for maternity care and asked it to advise if it had any safeguarding concerns. The Practice responded to the midwife stating, ‘GP is very concerned for her mental wellbeing, and she was declined fertility services as {she was} considered not to be in a position to care for a baby on her own’.

27. On 27 March 2025, the Multi-Agency Safeguarding Hub for Child and Family (MASH C&F) reached out to the Practice. It stated it received a referral from Miss B’s midwife and required clarification on the mental health, wellbeing and fertility services information the Practice had shared with Miss B’s midwife. MASH C&F requested the GP respond in a timely manner as it had 24 hours to make a decision.

28. The records indicate MASH did not complete the referral within their required timescale due to capacity issues and because it needed the information from the GP.

29. The records state the safeguarding referral was uploaded but left incomplete. Practitioners working with Miss B were advised to contact Children’s Social Care if they required information or had concerns to share.

30. The records show at 9:29am on 1 April 2025, during a consultation, Miss B informed the Practice IVF was not declined rather, she could not get the loan for the £12 000 required. At 1:03pm same day, the GP sent their observations to MASH stating, ‘child is cause for concern’, meaning there were reasons to worry about their safety or wellbeing.

31. The records show the Practice updated Miss B's GP records from incorrectly stating she had been declined IVF to reflect she could not afford it. The Practice also informed her midwife of the error, and the midwife made the necessary corrections to Miss B's records.

32. In its complaint response, the Practice acknowledged Miss B was not declined IVF rather she could not raise the funds for it. It stated it had clarified this information with her social worker.

33. GMC Good Medical Practice states to help keep patients safe, doctors must contribute to confidential inquiries and take part in incident reviews or investigations.

34. GMC Confidentiality Good Practice states patients have a right to keep their medical information private but sometimes doctors must balance this with their duty to protect and promote the health and welfare of patients unable to protect themselves.

35. GMC Protecting Children states you can share confidential information without consent if sharing will protect a child or young person more than keeping the information private.

36. Miss B’s complaint concerns the Practice sharing her information without her consent or knowledge. Miss B’s records show the information was requested by MASH C&F to confirm aspects of her medical history for the safety of her unborn baby. The request was based on concerns relating to Miss B’s health and the welfare of the child. In responding, the Practice acted in line with GMC guidance, which allows sharing relevant information to protect a child or young person. We have not seen any indications of failings in the Practice sharing information to MASH C&F without Miss B’s consent.

37. Miss B also complains the information the Practice shared about her IVF was incorrect, specifically that she was declined IVF treatment. We reviewed her records and all correspondence between the Practice and the IVF centre to determine whether the Practice was aware of the reason her IVF did not proceed.

38. The records indicate the Practice was not informed of the decision regarding her IVF outcome. The letters exchanged focused solely on her health conditions, and there is no documentation showing she did not proceed with IVF due to cost. It is unclear how the Practice came to incorrectly record ‘declined fertility services as {she was} considered not to be in a position to care for a baby on her own’. This led to the Practice sharing incorrect information with MASH. This indicates a failing by the Practice. We will consider the impact later in this report.

Incorrect dosage

39. Miss B says on 15 April 2025 the Practice prescribed her an incorrect dosage of labetalol, a beta blocker used to treat high blood pressure.

40. We reviewed her records and sought clarification from the Practice about how they managed Miss B’s blood pressure.

41. The Practice explained, both it and Miss B’s midwife, were monitoring her blood pressure throughout her pregnancy.

42. In January 2025 records show Miss B’s midwife sent a letter to the Practice informing it that at Miss B’s appointment on 8 January she was hypertensive with a blood pressure of 147/103. They noted she had chronic hypertension and requested the Practice discuss this with Miss B and prescribe alternative blood pressure (BP) medication which was safe for pregnancy.

43. The Practice acted on this advice and first prescribed labetalol on 17 January at a starting dose of 100 mg twice daily (200 mg total). Over the following weeks, Miss B’s blood pressure was monitored closely.

44. On 20 January, her blood pressure was 134/98; on 27 January, it was 120/98.

45. On 3 February, her blood pressure was 130/94, and the GP advised increasing her evening dose of labetalol to 200 mg. She was prescribed a new dosage of 100 mg in the morning and 200 mg at night (300 mg daily)

46. On 10 February, her blood pressure was 124/85, and the same dose of labetalol (100 mg in the morning, 200 mg at night) was continued.

47. On 17 February, her blood pressure was 124/85.

48. On 17 March, her labetalol dose was increased further to 200 mg twice daily (400 mg daily).

49. On 1 April, her blood pressure was 148/104. Records show her GP planned to increase her labetalol medication to 100mg twice daily, but there is no evidence in the prescription records this was acted upon. The Practice’s complaint response states the plan was to increase her dose to 200mg twice daily.

50. Miss B was next prescribed labetalol on 15 April following a blood pressure review with her midwife on 14 April. On this occasion, she was prescribed 200 mg twice daily (400mg daily).

51. In its complaint response, the Practice says Miss B remains on a low dose of Labetalol 200 mg twice daily (400mg) and her BP was currently well controlled, maintain at the desired target of 135/85 mg.

52. NICE guidance on hypertension in pregnancy states women with chronic hypertension should be treated with Labetalol. It is considered safe during pregnancy. It is commonly given to pregnant patients with existing hypertension or those who develop pregnancy induced hypertension.

53. The BNF recommends starting adults on 100 mg twice daily (200mg), with the dose increased every 14 days if needed. The usual dose is 200 mg twice daily (400mg).

54. Our clinical adviser explained the Practice had a good system for regularly monitoring and recording Miss B’s blood pressure, which reflects good clinical practice.

55. Miss B was first prescribed Labetalol on 17 January at a dose of 100 mg twice daily (200mg) in line with NICE guidance on hypertension. Three weeks later, on 10 February, when her blood pressure remained high, the Practice increased the dose to 100 mg in the morning and 200 mg at night (300mg). This was in line with NICE guidance as it was more than 14 days between her starting the medication and the Practice increasing the dose. Similarly, it acted in line with NICE guidance when it again increased the dose to 200 mg twice daily (400mg) on 17 March.

56. We have seen no evidence Miss B was prescribed an incorrect dosage on 15 April. We have seen the Practice followed the recommended dose as stated in NICE guidance and BNF. It increased the medication gradually and did not exceed the required maximum dose of 200 mg twice daily (400mg). As we have not seen any indications of service failings we will be taking no further action on this part of Miss B’s complaint.

57. We hope our findings and explanation provide Miss B with reassurance.

Effect of medication

58. Miss B complains the Practice never informed her of the effects of the medication labetalol, stating it affected her and her baby. She says the medication caused her a persistent wheezy cough and affected her baby’s blood glucose levels after birth.

59. GMC Prescribing Good Practice states clinicians must give patients information that suits their condition, explain possible risks, check the patient’s understanding, and encourage them to ask questions.

60. BNF lists the recognised side effects of Labetalol, such as dizziness, fatigue, nausea, headache, slow heart rate, diarrhoea, sleep problems, and others. A wheezy cough is not listed as a known side effect.

61. Our clinical adviser explained although a wheezy cough is not in the BNF, it is clinically recognised that beta blockers such as Labetalol can sometimes cause breathing related symptoms. Beta blockers slow the heart and reduce how hard it has to work. If a patient develops unexpected symptoms they are expected to inform their GP so the medication can be reviewed.

BNF Labetalol also notes the medication can slow a baby’s growth in the womb and may cause low blood sugar or a slow heart rate in newborns, especially when the mother has severe hypertension. Our clinical adviser explained these effects are well known and it is the responsibility of secondary care to monitor the baby after birth once it’s determined the mother had been on Labetalol.

62. We could not find any evidence in Miss B’s medical records that the Practice explained these possible risks to Miss B. This indicates a failing as, in line with GMC guidance, the Practice should have discussed the risks with Miss B and checked her understanding before prescribing the medication.

Impact

63. We have seen indications of failings in the Practice sharing incorrect information about the outcome Miss B’s enquiries about fertility treatment and it not informing her of the side effects of labetalol.

64. Miss B says the Practice sharing incorrect information to social services caused her significant distress, contributed to the escalation of her PTSD symptoms and caused her to lose trust in the professionals involved in her care.

65. She says the Practice’s failure to inform her about the effect of the medication, caused her son to experience blood sugar instability after birth requiring hospital monitoring which disrupted the immediate postnatal period, prevented early bonding, and made it difficult for her to start breastfeeding.

66. She also says the Practice actions affected her ability to engage with healthcare services and affected her wellbeing during her pregnancy.

67. As an outcome of her complaint, Miss B would like the Practice to acknowledge their wrongdoing, an apology and service improvements.

68. It is clear from the records the Practice shared incorrect information with the midwife, which subsequently informed a referral to MASH. When Miss B raised her concern about the Practice’s information being incorrect, it rectified it and informed MASH.

69. MASH later sought clarification on the information originally provided by the GP. The Practice responded promptly, expressing concerns about the child’s welfare but made no mention of Miss B being denied IVF. The response to MASH’s request was included in her records.

70. Our Principles of Good Administration say organisations should acknowledge mistakes and put them right quickly and effectively.

71. We have seen the Practice acted in line with our Principles as it promptly recognised its mistake, corrected Miss B’s records, and informed relevant organisations of the error. We have seen evidence of these corrections in her GP records and in records held by her midwife, which now accurately state that she was not denied IVF but was unable to afford it.

72. Miss B’s distress aligns with level one of our Severity of Injustice scale, where the effect is of short duration with no ongoing or wider adverse impact. The records have since been rectified, which suggests that the incorrect information will have no further impact on Miss B.

73. The Practice acted in line with our Principles by acknowledging its error, issuing corrections, and taking appropriate steps to put things right.

74. We noted in the complaint response, though it acknowledged its error, the Practice did not issue Miss B an apology for sharing incorrect information. Consequently, we contacted the Practice and asked them if it would be willing to resolve this complaint. Specifically, we asked it to issue an apology to Miss B for the impact of it sharing incorrect information. The Practice agreed to issue an apology.

75. We hope Miss B feels reassured that her records now accurately reflect her situation and that the misinformation had no effect on her baby’s care. We also hope the remedies already implemented by the Practice, including the acknowledgment of their error, provide her some comfort moving forward.

76. Miss B says the Practice’s failure to inform her about the effect of the medication, caused her son to experience blood sugar instability after birth requiring hospital monitoring which disrupted the immediate postnatal period, prevented early bonding, and made it difficult for her to start breastfeeding.

77. Our clinical adviser explained Labetalol was the only clinically appropriate medication for Miss B. She had none of the contraindications listed in BNF. Contraindications are the reasons why a medicine should not be used.

78. They further explained it is well known within the clinical field that labetalol can sometimes affect a baby’s blood sugar levels. In such cases, standard procedures require hospital staff to monitor the baby after birth, as occurred in Miss B’s situation.

79. We understand it is common clinical knowledge that Labetalol can affect a baby’s blood sugar levels. We can also see that if the Practice had informed Miss B of this potential effect, it would have provided her with an opportunity to consider her options or to mentally prepare herself for the impact the medication could have on her baby after he was born.

80. We recognise how distressing this experience must have been for Miss B, having to witness her baby suffer blood sugar instability at a time when she was physically recovering from birth and emotionally worried about her son’s health.

81. The impact on Miss B and her baby aligns with level one of our Severity of Injustice Scale. This level describes cases where the effects are of short duration with no ongoing or wider adverse impact. In such situations, we typically consider an apology to be an appropriate remedy.

82. We also asked the Practice to issue an apology to Miss B for not informing her about the effect of the Labetalol in line with guidance. The Practice agreed to issue an apology and acknowledge its failings and the impact they had on Miss B.

83. As a result of Miss B raising this complaint, the Practice has been reminded of the importance of informing patients about the effects of medication when prescribing it. We consider Miss B’s complaint has resulted in a service improvement within the Practice.

84. We believe the actions taken by the Practice align with our Principles. Given that the Practice has addressed this matter appropriately, we do not think any further action is required from us on this part of Miss B’s complaint. We hope this outcome provides reassurance to Miss B.

1. We have carefully considered Miss B’s complaint about a Practice in the Cambridgeshire area (the Practice).

2. We have seen no indications of failings in Miss B’s complaint about the dosage of medication the Practice prescribed her, or in it sharing information without her consent.

3. We found the Practice has already taken reasonable steps to address the effect of it sharing untrue IVF information and of it not informing Miss B about the potential effects medication may have had on her. As a result of Ms B’s complaint to us, the Practice have agreed to apologised to Miss B for the effect its failings had on her.

4. We will explain our reasons for our decision in this statement.

5. Complains give us valuable insight into the organisations we investigate, so we would like to thank Miss B for sharing her experience with us. It is also important to acknowledge that us not finding indications of service failure does not detract from Miss B’s experience or the upset these issues caused her.