Baby not given best chance to survive

What happened

Mrs M was 22 weeks pregnant and suffered vaginal bleeding and pain in her lower abdomen. She went to A&E in winter 2012 where her urine was tested and she was told she had a urine infection. She was discharged into the care of her GP.

During the day Mrs M's symptoms worsened and she went back to A&E. She was later transferred to the maternity ward where she was found to be in advanced labour. Her contractions stopped the next morning but she stayed in the hospital for several days. She was then transferred to another trust's hospital. When she arrived, doctors discovered that her baby had died.

Mrs M complained about the care and treatment received on both visits to the Trust's A&E, and also about the way it responded to her complaints.

What we found

When Mrs M first went to A&E, doctors did not assess her condition adequately or arrange the investigations and treatment she needed. Although the doctors took her history, some of the key information was inaccurate.

They also failed to carry out an internal examination and this meant that their decision to discharge her was not based on all the relevant information. Mrs M was seen by an inexperienced doctor who was new to the team. The Trust's own policy said that Mrs M should have been seen by an experienced member of the obstetrics/gynaecology team. The care and treatment Mrs M received fell far below what it should have been.

Lastly, the Trust took an unreasonably long time to respond to Mrs M's complaint, did not keep her updated and did not provide reasons for the delays.

The Trust acknowledged that, had doctors taken an accurate history when Mrs M first arrived in A&E, she would have been seen in the labour suite straight away.

We could not say that Mrs M's baby would have survived  if her care had been different. But what we could say was that her baby would have stood the best chance, however small, of surviving. We recognised that this was an added distress for Mrs M and her partner, and an injustice to them.

We also found that Mrs M suffered distress because of the Trust's handling of her complaint.

Putting it right

The Trust apologised for its failings and put together an action plan that showed learning from its mistakes.  It paid Mrs M £750 to acknowledge the impact these failings had on her and her partner.