Lewisham and Greenwich NHS Trust

41. 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.

42. 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.

What we found

43. Through investigating this complaint, we found that the Trust rushed to use instruments in Miss L’s birth. We think there was missed opportunity for her to continue her delivery without them. This may have reduced her risk of the third degree tear. This has left Miss L with uncertainty about whether the complications she has experienced could have been avoided. We think there is more for the Trust to do to remedy this.

What the Trust should do

44. 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.

45. We recommend that, within four weeks of our final report, the Trust write to Miss L (with a copy sent to us). The Trust should acknowledge that it failed to act in line with the NICE Intrapartum care guidelines, and it should apologise for the distress and uncertainty Miss L has experienced.

46. 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.

47. 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.

48. Following this review, we think that the Trust should pay Miss L £375. This is in recognition of the missed opportunity for the Trust to have reduced the risk of Miss [name redacted] experiencing a third degree tear, and the uncertainty about whether this could have been avoided. We ask that the Trust does this within four weeks of the date of our final report.

49. These principles also say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

50. We also ask the Trust to, within three months of our final report, produce an action plan. This should consider why the identified failings occurred and set out the actions the Trust is taking, or will take, to prevent the failings from occurring again.

51. The action plan should also explain who is responsible for each of these actions, when the actions will be completed, and how and when the actions will be reviewed to ensure they have been completed and have had the desired effect.

52. The Trust should produce this action plan within 12 weeks of our final report. A copy of the action plan should be sent to Miss [name redacted], to us, to the Care Quality Commission (CQC), and to NHS England.

4. Miss L complains that when giving birth at the Trust in spring 2022, the Trust used instruments during the birth, and it did not provide an alternative.

5. Miss L tells us that as a result of the use of instruments she suffered a third degree perineal tear (3b tear). She believes this has led to her suffering incontinence and pain during sex. She tells us that she does not go out of the house often as she is afraid she will be incontinent, and her issues have affected her mental health.

6. Miss L would like service improvements, and compensation.

7. Miss L gave birth to her daughter in spring 2022 after an induction of labour (IOL). She had previously stated her preference for a planned caesarean section (c-section).

8. Miss L attended the hospital for her IOL and the Registrar offered either a hormonal pessary or a non-hormonal pessary. During her first examination, staff found that she was 3cm dilated with a Bishop score of 7. The Bishop score is a numerical score obtained by doing a vaginal examination before labour, to assist staff in predicting whether an induction of labour will be needed.

9. Staff then transferred Miss L to the delivery suite for an artificial ruptured membranes (ARM). This is the procedure used to break the waters, which can start or speed up labour. At this point, staff recorded Miss L’s Bishop score as 6.

10. Miss L asked for a second opinion at this stage as she believed she was supposed to have a pessary and not an ARM. The doctor recommended proceeding with the ARM. Miss L feels that this was not a valid second opinion as she had already spoken to this doctor. She felt she had no other option but to have ARM.

11. Miss L started to experience contractions without further intervention. Sometime later, the midwife noted Miss L had a small amount of bleeding, and shortly after this, there was a change to her baby’s heart rate.

12. The obstetric team reviewed Miss L, examined her and noted she was fully dilated, and the baby’s head was low in her pelvis. The baby’s heart rate initially recovered, but there were further concerns about the baby’s condition. The Trust decided to expedite the delivery, via the use of a ventouse cup and forceps. Miss L feels she was not offered an alternative at this point. She feels she should have been allowed to have a c-section.

13. The Trust initially tried using the ventouse cup, but this was not successful, so it decided to use forceps. Despite the Trust making a cut to Miss L’s perineum during delivery, she experienced a 3b tear. She says she is still suffering from the effects of this.

17. Miss L complains the Trust used instruments during her birth and did not provide an alternative.

18. The Assisted Birth guidelines outline types of assisted vaginal birth and when assisted birth is appropriate. The guidelines explain that no indication is absolute, and clinical judgement is required in all situations. The guidelines also say the indications for an assisted vaginal birth include suspected foetal compromise, lack of continuing progress in labour for three hours with analgesia (or two hours without), maternal exhaustion or distress.

19. The Assisted Birth guidelines also classifies types of assisted birth depending on where the baby is positioned in the birth canal. The categories are dependent on where the foetal skull has reached in the perineum (a region of skin and muscle located between the vulva and the anus).

20. Station refers to the position of the baby’s presenting part (usually the head) in relation to the mother’s pelvis. A +1 to +5 measurement indicates how many centimetres the baby has descended in the birth canal. A low assisted birth is where the foetal skull is at station +2cm but not yet at the perineum. A mid assisted birth is where the skull is at station or +1cm.

21. The NICE guidelines provide guidance around when to offer birth with forceps or ventouse cup (a suction cup that is attached to the baby’s head). This includes if there is concern about the baby’s wellbeing, there is a prolonged second stage of labour, or the woman requests assistance.

22. The records show the Trust was concerned about the baby’s heart rate pattern (shown on the cardiotocography, CTG). The Trust felt would be considered suspected foetal compromise.

23. The records show the Trust was concerned about the baby’s heart rate as it had decreased at 12.49pm. Our adviser has told us that the heart rate prior to this was stable and showed the baby in good condition. The baby’s heart rate increased after 3 minutes. It decreased again 12.57pm but again quickly resolved itself.

24. Our adviser has said that the baby’s heart rate recovered after a maximum of three minutes of deceleration. It then remained normal for 5 minutes before the Trust started to reposition Miss L and started to use instruments. They have also said that after the heart rate returned to normal, the variability of the baseline remained normal and did not suggest the baby was hypoxic.

25. The records show that at the time the instruments were used the baby’s head was at station +1 which would mean it was a mid assisted birth. Our adviser has also said given the position of the baby, this was a slightly more difficult position. They said it would have been reasonable to allow some time for the baby’s head to descend further.

26. We note the Trust proceeded with the instrument delivery due to concerns about the baby’s wellbeing. Our adviser said there was no immediate indication for instrumental delivery, as the CTG shows baby’s heart rate had recovered. They have said it would have been reasonable for the doctors to watch the heart rate closely. If the heart rate remained normal the labour could have continued.

27. If the heart rate decelerated again, instrumental delivery may have been necessary later. However, it is likely that the baby’s head would then have been lower in the pelvis. This would mean the delivery was easier and less prone to complications, such as a third degree tear. It could have also decreased the need for two instruments to be used (the ventouse cup, followed by the forceps) which our adviser has said increases the risk of significant tearing.

28. It appears that the Trust’s decision to use instruments in Miss L’s delivery is not in line with the NICE guidelines. We recognise the Trust documented it had concerns about the baby’s wellbeing, and that clinical judgement should be used in the circumstances. We think the evidence shows these concerns were premature, and there was a missed opportunity for the trust to undertake further observation.

29. We have found a failing in the actions of the Trust here. We think the Trust prematurely used instruments to assist with the delivery of Miss L’s baby, rather than continuing to observe her. We cannot say the need for using instruments could have been avoided. Our adviser has said it is not possible to rule out the possibility that instruments would have needed to be used later. We have gone on to consider the impact of this failing for Miss L.

30. Miss L has told us as a result of the use of instruments she suffered a third degree perineal tear (3b tear). She tells us that since this happened she has suffered incontinence and pain. This has also affected her mental health.

31. Our adviser has confirmed that a less hurried delivery using instruments, or the possible avoidance of instruments, would have reduced the risk of the third degree tear. Our adviser explained that a third degree tear is possible in any vaginal delivery, however the use of instruments increases the risk of this.

32. Our adviser has said that incontinence is a likely result of third degree tearing. They have said that pain during sex can occur after any vaginal delivery, so this may have still occurred, however it is likely the severity of this could have been reduced.

33. In summary, we think the failing we have provisionally identified has meant the risk of Miss L experiencing a third degree tear could have been reduced. This has led to uncertainty for Miss L about whether the third degree tear she had, and the associated complications from this, could have been avoided.

34. We have gone on to consider the Trust’s response to this issue, and whether it has done enough to remedy the impact of this provisionally identified failing. Our NHS complaint standards set out how organisations providing NHS care should approach complaint handling.

35. These standards say that organisations should see complaints as an opportunity to develop and improve its services and people. It says responses should be fair and accountable, setting out what happened and whether mistakes were made. It should set out how the organisation is accountable and take action to make sure any learnings are identified and used to improve services.

36. The Trust has recognised the instruments used are commonly associated with the type of tear that Miss L suffered. It has said that its decision was in line with guidelines. It said it was sorry to hear Miss L had experienced pain and continence issues since the delivery.

37. The Trust has said that because the baby’s heart rate began to cause concern for a second time it was felt the most appropriate action was to expedite the delivery. The Trust has said the baby was low in the pelvis and so delivery would be most rapidly achieved with ventouse cup or forceps. The Trust has said that Miss L was transferred the theatre for a repair of the tear she sustained.

38. We consider the response from the Trust goes someway to put things right here. It said it was sorry to hear about the pain and health issues Miss L has experienced since the events in the complaint. However, we do not think the Trust’s response goes far enough to put things right here.

39. The Trust’s response acknowledges the pain and continence issues Miss L has experienced. But it does not acknowledge that any mistakes were made which may have increased the likelihood of the tear happening. It also does not outline any learning needed to prevent this from happening again.

40. We therefore think there is more the Trust can do to recognise the full impact the failing we have provisionally identified had on Miss L, We also think there is more the Trust can do to ensure something similar would not happen again. We have set out our recommendation in relation to this below.