Trust's poor communication led to a distressing labour and delivery

What happened

Ms R complained about the events around the birth of her second child at the Trust in 2013. A week after the birth, she was readmitted to the Trust with postnatal bleeding and infection caused by some of her placenta remaining in her uterus.

When Ms R went to the Trust in labour, staff assessed her and found she was in established labour but her cervix, which dilates to 10cm during labour, was only 2cm dilated. Staff monitored Ms R but delayed giving her pain medication, although she was in significant pain and had told a midwife that something was wrong.

Trust staff failed to assess the exact position of Ms R's baby at an early stage. Because she had only dilated a small amount, staff were concerned that her previous caesarean scar might rupture, so prepared her for a caesarean section. But, at the last minute, Ms R dilated and was able to have her baby delivered vaginally with forceps.

One week later, when she was at home, Ms R started sweating and shaking and had a foul–smelling blood discharge. She went to a routine appointment for the baby and told midwives about this. They did not take her temperature. Two days later, Ms R had heavy vaginal blood loss and went to the Trust's hospital, where she was unreasonably asked to wait in reception although she visibly needed urgent attention. Ms R suffered from retained placental products (part of the placenta had not been delivered during or after the birth). Trust staff manually removed these.

What we found

We partly upheld this complaint. It was evident that Ms R found her birthing experience very distressing. Had appropriate communication, support and pain relief been given, and if staff had identified the baby's position when Ms R arrived at hospital, her experience could have been quite different. We acknowledged that the Trust had taken some action in light of these shortcomings; however, we set out recommendations for further action.

There was no evidence to suggest that the clinical decisions about the delivery or the delivery itself were inappropriate, and the delivery by forceps was well–managed and followed national guidance.

While it was unfortunate that Ms R experienced a uterine infection after the delivery, there was no evidence to suggest that the care at delivery caused this. We identified that it might have been possible to intervene and treat the infection earlier if midwives had taken Ms R's temperature and found it to be abnormal. But we do not know that her temperature would have been raised, and additionally she did not present with symptoms that suggested a uterine infection. We therefore could not conclude that there was any remaining injustice but we made a recommendation in light of the missed opportunity to identify Ms R's uterine infection.

Although it was not appropriate that Ms R was asked to wait when she was actively bleeding on arrival at the Trust, records indicate that staff managed her haemorrhage and infection appropriately. Staff should have offered Ms R pain relief during the examination and the subsequent procedure to make this more tolerable. We noted that the community midwives recognised how distressed Ms R was and offered support. A post–natal debriefing occurred, both of which were reasonable steps.

Putting it right

The Trust wrote to Ms R acknowledging and apologising for the failings identified, and paid her £500 to acknowledge the pain and distress caused as a result of the missed opportunity to provide adequate pain relief, support and communication during the labour and delivery period. The Trust also prepared action plans to describe what it has done and/or plans to do to reduce the likelihood of similar shortcomings in the future