Ms B complained about the standard of care provided by Swansea Bay University Health Board (‘the Health Board’) between April and June 2023. The investigation considered whether the Health Board took into account her previous pregnancy loss when providing care, whether imaging scans and a cervical stitch procedure were conducted within an appropriate timeframe and whether the care provided to Ms B on 7 June 2023, when it was confirmed she would suffer a pregnancy loss, was appropriate.
The Ombudsman found that the Health Board’s records were contradictory about Ms B’s previous pregnancy loss, partly because of errors in the completion of the booking documentation (which, in places, indicated it was Ms B’s first pregnancy). Ms B should have been referred for consultant led care after the booking appointment on 19 April, as hers was a ‘high risk’ pregnancy, but this did not happen until Ms B questioned the delay in doing so, resulting in a delay of some 3 weeks.
It was also found that Ms B did not have the appropriate imaging scans at the appropriate time. As well as usual dating scans, she should have had a transvaginal ultrasound scan from 14 weeks. Instead, she had an abdominal ultrasound scan, and only at 16 weeks. If Ms B had had the appropriate imaging scan at the appropriate time, it is likely that the need for a cervical stitch, which was inserted at 16 weeks and 2 days, would have been identified sooner and inserted no later than 15 weeks. It is possible that, if this had been done, Ms B might not have suffered a miscarriage. The uncertainty is an injustice to Ms B. On 7 June Ms B could have been provided with Entonox sooner if she had been transferred to the labour ward earlier, and her cervical stitch would likely have been removed before her baby was delivered. The delay in transferring her and providing Entonox was an injustice to Ms B. All complaint points were upheld.
The Health Board agreed to the Ombudsman’s recommendations, including an apology to Ms B and to offer a payment of £1000 in respect of the injustices caused by the failings identified, including the significant emotional impact on Ms B. It will also share the investigation report with the Community Midwife Team, antenatal ward staff and obstetric clinicians for reflection and learning. It will review its internal procedures/guidance for midwifery and consultant led care, if not already in place, to ensure that they comply with the All Wales Preterm Birth guidance on consultant referral timeframes and transvaginal cervix screening in women who are at high risk. Finally, it agreed to establish a process to ensure and demonstrate that all relevant members of staff familiarise themselves with any such procedural updates.