Summary
C complained about the care and treatment provided by the board during a planned caesarean section. C said that complications occurred during the procedure which could have been avoided based on information available from antenatal scans. C also complained about the timing of the procedure, record keeping, delays in arranging a debrief meeting, postnatal care for high blood pressure and infection, and the board’s handling of the complaint.
We took independent advice from a midwifery adviser. We found that the care C received during the caesarean section was of a reasonable standard. It was reasonable to schedule C last on the theatre list due to an active COVID-19 infection, and there were no clinical indicators requiring enhanced planning. While complications occurred, we found that these were reasonably managed. We found that offering C the option of vaginal birth reflected good practice. We did not uphold this complaint.
In relation to C’s post-natal care, we found that the monitoring and management of blood pressure, infection treatment, and follow-up care were appropriate and in line with clinical guidance, and the medical records were accurate. We did not uphold this complaint.
We considered C’s complaint about the board’s handling of their complaint. We found that the board acted unreasonably by refusing to investigate on the grounds of time limits, despite the delay being due to a postponed debrief meeting and reassurances given that a complaint could still be made. The board did not provide a clear explanation for refusing to extend the timescale, contrary to complaint handling guidance. We upheld this complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
In relation to complaints handling, we recommended: Complaint investigations should be managed inaccordance with the Model Complaint Handling Procedure. The board should ensure that their complaints handling complies with the SPSO Statement of Complaints Handling Principles| SPSO. We offer SPSO accreditedComplaints Handling training. Details and registration forms for our onlineself-guided Good Complaints Handling course (Stage 1) and our onlinetrainer-led Complaints Investigation Skills course (Stage 2) are available athttps://www.spso.org.uk/training-courses.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202500492 as a PDF (26.79 KB) Updated: March 18, 2026