Investigations were not completed which meant the opportunity to deliver a baby early was lost. Later, lack of investigations led to a day of worry and distress for a couple before being told their baby had died.
What happened
Mrs A received antenatal care from the Hospital and she was seen at appointments at 33 and 36 weeks into the pregnancy. At 33 weeks it was noticed the baby's growth had slowed and at 36 weeks Mrs A reported the baby was not moving that morning. She was told to monitor the baby's movements and contact them if she remained concerned. That night she had further problems and returned to hospital. She was given an ultrasound which showed the baby had died. The baby was delivered and a post mortem done.
What we found
There were no failings in the care plan put in place for Mrs A's pregnancy. However there were failings in the care given to her at her 33 week and 36 week appointments.
The Trust should have made further investigations both at the 33 week and 36 week appointments. The missed opportunity to do this at 33 weeks meant an opportunity was lost to deliver the baby early. It is likely that this would have prevented Mr and Mrs A's baby's death.
We cannot say whether the failing to complete further investigations at 36 weeks would have avoided their baby's death, but it would have improved their experience and given them information about what was happening earlier.
We consider their distress as a result of this was further compounded by the Trust's poor record keeping and the inaccurate information which was given to them about the length of time the post mortem would take.
Putting it right
The Trust apologised and paid Mrs A £15,000. It has drawn up an action plan to improve its service.
West Suffolk NHS Foundation Trust
Suffolk
Not applicable
Apology
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan