Poor record keeping and poor communication with woman in labour who suffered complications after the birth

What happened

Mrs C went to the Trust's midwife-led delivery unit when she was in labour with her second child. She was concerned that her labour might progress very rapidly, as it had done with her first baby. She was admitted, but was then not checked for nearly three hours. Mrs C then needed to push. Her husband called for a midwife, who came to examine Mrs C but left the room to allow her time to undress. While the midwife was out of the room, the baby started to be born.

The baby was delivered safely but staff had trouble delivering the placenta, and transferred Mrs C to another hospital for surgery. There was a delay in reviewing her condition, and then she had to wait nearly two hours to be taken into theatre because of another obstetric emergency. During that time, her condition deteriorated, she haemorrhaged and her blood pressure dropped. Doctors successfully removed her placenta.

Mrs C needed blood transfusions after surgery and she also received counselling. She said there were communication problems and a midwife had made an inappropriate comment.

What we found

The Trust could not have prevented Mrs C from developing a retained placenta and the complications were not linked to the care she received. It had already acknowledged that the communication had not been as good as it should have been and that the midwife had made an inappropriate comment.

The midwife should not have left Mrs C unattended when she had urges to push. Mrs C was not monitored closely enough and the record keeping was inadequate. The Trust had written an action plan to address the midwife's actions but this had not been followed through.

Mrs C had initially been stable enough to wait for the surgery but her condition deteriorated and there was a delay in a senior doctor reviewing her. Even if she had been reviewed sooner, she would not have had surgery more quickly, because of the time it would have taken for an on-call doctor to arrive and a second theatre to be opened.

Putting it right

The Trust agreed with our recommendations and it apologised to Mrs C for the failings we found and paid her £500 for the distress she experienced. The Trust also revisited the action plan to make sure all the issues we found relating to the midwife, as well as our criticisms about the failures in monitoring and record keeping, had been addressed. It also took steps to improve communication with expectant mothers on admission.