University Hospitals Birmingham NHS Foundation Trust

5. Miss Z complains that during a night in early-January 2025, staff did not examine her and failed to recognise she was in labour.

6. She said because of this, her labour pain went unrecognised and she suffered a vaginal tear. Miss Z said this led to vaginal infections, being unable to sit for long periods of in certain positions, and toileting became painful. Miss Z said this has affected her mental health as she wakes in fear, reliving the traumatic incident and it has caused her trauma and suffering which she is taking medication to treat.

7. By bringing this complaint to us, Miss Z would like an apology, acknowledgement of failings, service improvements and a financial remedy.

8. This is a brief background to place the key events to this complaint in context. It does not provide a full account of everything that happened.

9. In early-January 2025, the Trust admitted Miss Z to hospital due to reduced foetal movements. Miss Z was 40+2 weeks pregnant at this time. The Trust referred Miss Z for an induction of labour (IOL).

10. The Trust induced Miss Z two days after admission, and her waters broke the following day in the early hours of the morning.

11. Miss Z gave birth approximately 26 hours later. On the day of delivery, Miss Z had a precipitate labour. This is where the baby is born less than three hours after the start of contractions.

15. Miss Z complains that during a night in early-January 2025, staff did not examine her and failed to recognise she was in labour.

16. The Trust explained there is a risk of infection when performing vaginal examinations which is why it does not perform this on request.

17. Sections 1.8.7, 1.8.8 and 1.8.9 of the labour guidance explains the following for assessment of women in the first stage of labour:

• if there is uncertainty about whether the woman is in established labour, a vaginal examination may be helpful after a period of assessment but is not always necessary • if the woman appears to be in established labour, offer a vaginal examination • be sure that the examination is necessary and will add important information to the decision-making process.

18. The Bishop score is a numerical value obtained by doing a vaginal examination. It is based on dilation, effacement (thin or shortened), position, consistency of the cervix (soft or firm) and how low the baby’s head is in the pelvis. In other words, it is used to assess how ready the cervix is for labour. The induction guidelines say a score of eight of more generally indicates that the cervix is ready to dilate.

19. When the Trust performed the IOL on Miss Z, she had a Bishop score of 0. There is no indication in the records Miss Z was having contractions at this time.

20. Approximately 13 hours after the IOL, Miss Z experienced a spontaneous rupture of membranes (SROM – sometimes known as ‘waters breaking’). An hour and a half later at 3.15am, the notes indicate Miss Z was having contractions and feeling some pain. Around 30 minutes later, the Trust noted Miss Z was having four contractions roughly every ten minutes.

21. Miss Z underwent a review by the obstetrician at 8.41am. The notes show Miss Z was experiencing tightening every five minutes with mild pain.

22. The Trust undertook a vaginal examination at 9am to determine progress of labour. The notes indicate Miss Z’s cervix was 3cm dilated, tilted toward tailbone or back (posterior), thin, soft, and 0.5cm to 1cm in length. The Trust documented a Bishop score of six. Our midwife adviser says this indicates some progress was being made in comparison to the score when the Trust induced labour.

23. At 2.15am the next day, Miss Z reported abdominal pain and asked the midwife if she could move her to the delivery room. The notes say the midwife advised Miss Z that the delivery room was too busy to move her and she apologised for this.

24. The records do not suggest Miss Z was experiencing strong contractions at this stage. However, our midwife adviser says there was a missed opportunity for the Trust here to consider whether she was in established labour.

25. By this point, the Trust had already found Miss Z was 3cm dilated, which was established the previous day and her cervix was soft. She had a Bishop score of six, which is only two points below what the induction guidelines says it when the cervix is ready to dilate (ready for labour).

26. Although there may have been uncertainty about whether Miss Z was in established labour at this stage, we think the information available to the Trust meant a vaginal examination would have been helpful. It could have helped determine whether labour was progressing and informed decisions about her care. We think the Trust’s lack of action here is not in line with the labour guidance

27. At 3.10am, less than an hour later, the Trust documented Miss Z was in established labour. Established labour is when there are regular contractions, and there is progressive cervical dilation from 4cm. However, there is no further documentation about what the Trust did at this time. For example, whether the Trust confirmed this by a vaginal examination as per the labour guidance. Due to the lack of notes here, it is unclear what actions the Trust took at this time.

28. The midwife performed a vaginal examination on Miss Z at approximately 4.37am as the notes say Miss Z reported feeling uncomfortable. The Trust documented Miss Z was 10cm dilated (fully dilated), with a Bishop score of 11 and in the second stage of labour. The Trust quickly moved Miss Z to the delivery room, and the baby was delivered at 4.54am.

29. Based on the evidence, we think the Trust missed an opportunity to examine Miss Z earlier than it did in line with the labour guidelines. We think this meant the Trust failed to determine earlier whether Miss Z was in established labour or not. We have found the Trust failed to undertake an assessment to establish whether Miss Z was in established labour at this stage.

30. We will consider the impact of this below.

31. Miss Z said because the Trust did not examine her and failed to recognise she was in labour, her labour pain went unrecognised and she suffered a vaginal tear. She said this led to vaginal infections, being unable to sit for long periods or in certain positions, and toileting became painful. Miss Z said this has affected her mental health as she wakes in fear, reliving the traumatic incident and it has caused her trauma and suffering which she is taking medication to treat.

32. We understand that giving birth so quickly is likely to have been frightening and overwhelming for Miss Z, particularly as this was her first baby. We recognise she continues to describe the experience as traumatic and how it caused her fear.

33. In her complaint to us and the Trust, Miss Z said she was in so much pain at 3am on the day of delivery, that she contacted her family at home. To help calm Miss Z down, she said her family took her outside the ward. There is a note at 3.59am which outlines that Miss Z had requested pain relief but that she was on her way out of the ward. Another midwife took the pain relief to find Miss Z and administer it to her. The records do not show when Miss Z first requested pain medication.

34. From when Miss Z reported being in extreme pain at 3am, she delivered her baby less than two hours later.

35. Our midwife adviser explains the Trust was providing regular CTG (monitoring a baby’s heart rate) every six hours. This would have provided Miss Z with an opportunity to express she was in pain and request pain relief. In the records, the Trust documented that it offered Miss Z pain relief on multiple occasions which Miss Z declined. Based on the evidence we have seen, we cannot say the missed opportunity to examine Miss Z earlier meant the Trust did not recognise her labour pains.

36. We acknowledge being in labour can be extremely painful. We do not underestimate the pain and distress Miss Z has told us she experienced during these events. We also recognise that Miss Z had already been in hospital for four days at the time of the events complained about. Our midwife adviser thinks this may have impacted Miss Z’s perception of how long the labour had been.

37. Regarding the failing of the Trust missing the opportunity to examine Miss Z earlier, we asked our obstetric adviser whether this contributed to Miss Z experiencing a precipitous labour.

38. Our obstetric adviser explained the precipitate labour was not caused by the Trust not establishing she was in labour sooner. They say Miss Z’s labour was a natural process, and the speed at which the labour advanced could not have been changed by intervention.

39. In terms of experiencing a vaginal tear, Miss Z suffered a second-degree vaginal tear. This involves the skin and muscles of the perineum (the area between the vagina and anus). Our midwife adviser explains that approximately 29 to 41 percent of women experience a second-degree tear during vaginal childbirth. These tears are the most common type of injury requiring stitches. For first-time mothers, the risk is higher with rates reported between 35.1 and 78.3 percent.

40. We also asked our obstetric adviser whether the precipitate labour contributed the Miss Z suffering a vaginal tear. They said that, to their knowledge, there is no evidence that precipitate labour increases the chance of perineal injury or vaginal tearing. A vaginal birth, as explained earlier, does carry the risk of vaginal tearing. Our midwife adviser explains that even if Miss Z’s labour had been slower, she may still have suffered a perineal tear.

41. We appreciate how Miss Z says the whole experience was traumatic and how it has had a lasting impact on her. Going through labour and childbirth can be a traumatic experience for a woman. In this case, we think that if the Trust offered to perform a vaginal examination on Miss Z earlier, this might have provided her with some reassurance about the progress of her labour.

42. We can understand this lack of examination may have heightened any distress and stress Miss Z was experiencing at the time. Our midwife adviser explains that whilst many pregnant women often hope for a quick labour, it can also be distressing when this happens. They say some women can feel a sense of being out of control over what is happening.

43. We recognise Miss Z considers the lack of examination to be an important part of what made this experience so distressing. However, we must look at all of the circumstances that were affecting her at the time.

44. The Complaint Standards say staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.

45. From the Trust’s written response to Miss Z’s complaint, we can see a matron spoke with Miss Z about the complaint and apologised for her experience. The matron also spoke with her about Miss Z’s concerns about the lack of examinations when she was in a lot of pain. It is not clear from the Trust’s written response what explanations the matron gave regarding this, and whether this was specifically related to the lack of vaginal examinations.

46. Nevertheless, we do not think the apologies and explanations given fully reflect the distress Miss Z experienced. Specifically in relation to the lack of examination. We think the Trust can do more to put things right here.

47. We will outline our recommendations below.

1. We were sorry to hear of the events Miss Z has described, and the impact she says these events have had on her physical and mental health. We understand this was a difficult time for her as well as the ongoing impact she continues to experience.

2. We have found a failing in relation to the Trust performing a vaginal examination on Miss Z earlier on the day of delivery. This meant there was a missed opportunity to determine whether Miss Z was in established labour or not. We consider this led to Miss Z experiencing further distress and stress at the time.

3. We cannot say the Trust’s lack of action led to it failing to recognise her labour pain, or that this caused her to suffer a vaginal tear. Nor can we say this was the only cause of the distress and traumatic experience Miss Z went through.

4. We recommend the Trust apologises and pay Miss Z £200 in recognition of the impact of the failings found. We also recommended the Trust to complete an action plan to address the failing we have identified, to reduce the risk of them occurring.

48. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

49. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. 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.

50. We have identified failings in relation to the missed opportunity of the Trust to perform a vaginal examination of Miss Z earlier on the day of delivery. This meant a missed opportunity to determine whether Miss Z was in established labour or not. We consider this led to Miss Z experiencing further distress and stress at the time.

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

• writes to Miss Z within four weeks of the date of the final report to acknowledge the failing we have identified and apologise for the distress and stress this caused her (as summarised in paragraph 50) • pays Miss Z £200 within four weeks of the date of the final report, in recognition of the further distress and stress she experienced as a result of the failing

• explains what action it will take, or has taken, to address these failings. It should do this in the form of an action plan which should be shared with us, Miss Z, NHS England (NHSE) and the Care Quality Commission (CQC) within 12 weeks of the date of the final report. The action plan should include the reason for the failing (where possible), what the Trust does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored

52. We will ask the Trust to send us evidence it has completed all of the recommendations we make in the final report.