Failure to communicate and follow national guidance
The complaint
Miss A complained about some of the care Barts Health NHS Trust gave her in 2020 during her pregnancy and labour, and after her baby was born.
She complained staff did not investigate her bleeding during her pregnancy and did not give her proper care after her baby was born.
She said staff did not explain her delivery options or give her proper information about the haematoma (a bruise caused by a small pool of blood under the skin) on her son’s head.
She said the experience made her feel low and caused her anxiety about whether she will be able to have children in future.
Miss A wanted the Trust to improve its service to make sure this does not happen to anyone else. She also wanted compensation.
What we found
Staff did not do ultrasound scans to investigate Miss A’s bleeding during her pregnancy between 3 and 4 January 2020. They should have done. This caused anxiety for Miss A.
When Miss A went back into hospital, staff did not properly explain her delivery options or the induction of labour process (where labour is started artificially). Staff should have explained this clearly.
After Miss A had her baby, her placenta did not deliver naturally as it should. This is called a retained placenta. Staff removed Miss A’s placenta manually but did not do it in an operating theatre under anaesthetic, which meant they did not remove a large part of it. This did not follow the Trust’s policy. It also meant Miss A experienced pain and needed two more operations months later to remove the rest of the placenta.
Staff did not properly explain the haematoma on Miss A’s baby’s head to her before she left the hospital.
Putting things right
We said the Trust should make sure its communication is in line with the Nursing and Midwifery Council and General Medical Council standards.
We said it should keep full records of any discussions about scanning women who are bleeding. It should follow National Institute for Health and Care Excellence guidance when it is having these discussions.
We said it should make sure staff know about its policy for manual removal of retained placenta, where this should happen and under what conditions.
We said it should share an action plan with Miss A to explain how it will make these changes to help stop the failings happening again.
We recommended the Trust pay Miss A compensation for how its failings affected her.