When Mrs J went into labour, midwives failed to monitor her progress or make sure that the pain relief she was given was adequate.
What happened
Mrs J suffered from tocophobia (the fear of being pregnant or of giving birth) during her antenatal visits and she and Trust staff planned for her to have her baby by caesarean section. The day before she should have been admitted, she went into labour and arrived at the maternity unit when she was already 3cms dilated. It was confirmed she would have a caesarean section but her labour progressed very quickly and she gave birth naturally before a theatre was available.
What we found
We decided that the Trust appropriately classified Mrs J as a 'category 3' caesarean section. However, her care in labour could have been managed better. There was no evidence that she was either observed or monitored regularly, or that her gas and air pain relief was sufficiently helping her. There was also no evidence that staff considered her need for particular reassurance in the face of her known anxiety.
We also decided that even if staff had monitored Mrs J appropriately, it might not have been possible to carry out the caesarean section. However, her overall experience could have been better with more adequate pain relief and reassurance.
Putting it right
The Trust apologised and paid Mrs J compensation of £500. It put a plan in place to make sure these failings did not happen again.
University Hospitals Coventry and Warwickshire NHS Trust
West Midlands
Did not apologise properly or do enough to put things right
Apology
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan