Lack of patient observations and poor record keeping

Mrs Y went to hospital for a planned caesarean section. There were no issues with the caesarean and she gave birth to a healthy baby boy. Mrs Y was recovering well in hospital but three days after giving birth she was found unconscious in her chair. She died despite attempts to resuscitate her. A pathologist initially reported the cause of Mrs Y's death as postpartum sepsis. The Trust felt there was not enough evidence to identify sepsis. It commissioned a second pathologist's report which put the cause of death as cardiac arrest.

Mrs K complained that her daughter's consultant had not been present and that three or four different midwives had been assigned to her within the first few hours. Mrs K also complained that the Trust had not monitored her daughter appropriately after the birth and that its resuscitation procedures were not effective. She also raised concerns about the Trust's record keeping.  Mrs K said she believed her daughter's death could have been avoided if she had received appropriate care and treatment.

What we found

The Trust failed to monitor Mrs Y in line with local and national guidelines. Although she was not observed as often as she should have been, the observations that staff did take were normal, and there was nothing to indicate any problems with her recovery. We saw no suggestion that Mrs Y's observations would have been anything but normal even if they had been recorded more frequently, and so it is likely her care and treatment would have been the same had the service failure not happened.

The standard of the Trust's record keeping was poor and it did not keep clear and accurate records. We found no fault with the attempts to resuscitate Mrs Y.

Mrs Y did not receive the standard of care she should have done and knowing this has caused Mrs K great distress and anxiety. However, we did not find Mrs Y died because of failings by the Trust, and for that reason we partly upheld Mrs K's complaint.

Putting it right

The Trust wrote to Mrs K to acknowledge the service failure and to apologise for the distress this caused her and her family. It also drew up plans to prevent the same mistakes happening again and explained these changes to Mrs K.