Patient unable to access support from maternity unit when she arrived in established labour

What happened

Mrs K went to the maternity unit as she was having regular contractions. After staff monitored her, they told her that she was not in established labour and to go home. Mrs K says that she was told that if she was in labour she 'would be shouting like the other women on the unit'. She says that she was told to go home and not to return within the next four hours as she would be 'wasting their time'.

Mrs K was in severe pain at this time and could barely walk. However, because of the instruction not to return to the maternity unit for four hours, she went home. Soon after arriving home Mrs K gave birth in her bathroom without any medical support.

Mrs K said that she was left traumatised by the experience and could not bond with her baby for some time afterwards. She complained to the Trust about the lack of care she received from the staff at the maternity unit. She wanted improvements to be made at the Trust to make sure this does not happen again. She also asked for a financial remedy for the distress caused her.

The Trust said that Mrs K's assessment was appropriate but acknowledged some failings in communication. It declined to consider any financial remedy.

What we found

A student midwife carried out the examinations and some were not checked by a trained midwife. It was therefore difficult to establish if the clinical examination had been appropriate. The records did not reflect Mrs K's version of events or the clinical findings. On the balance of probabilities, we concluded that Mrs K was in established labour and should have been admitted to the maternity ward. These failings were exacerbated by the poor communication and left Mrs K feeling that she could not return to the maternity unit, despite being in significant pain. The Trust acknowledged and apologised for the communication problems but failed to understand the seriousness of the impact on Mrs K. It was unreasonable for the Trust to refuse to consider a financial payment for the distress caused by the failings.

Putting it right

The Trust apologised to Mrs K for its failings and paid her £1,000 in recognition of the distress caused. It also produced an action plan to address the failings identified.