Failure to offer to try to start labour sooner
The complaint
Miss C’s daughter sadly died ten days after she was born in 2018. Miss C complained about the maternity care and treatment St George’s University Hospitals NHS Foundation Trust gave her.
This included her 40-week appointment, her 41-week appointment and when she went into the labour ward to give birth.
She also complained about how the Trust communicated with her and investigated what happened.
She wanted the Trust to apologise, acknowledge its failings and stop them happening again. She also wanted compensation.
What we found
The Trust did not offer Miss C a membrane sweep (also known as a cervical sweep) at her 40-week appointment. This is where the midwife or doctor sweeps their finger around the cervix in an internal examination to bring on labour. This did not happen because the Trust’s policy was not clear and was not in line with National Institute for Health and Care Excellence guidance.
It was a missed opportunity because the results could have sent Miss C into labour sooner. She believed going into labour sooner may have given her baby a better chance of survival. We cannot say if this would have improved her baby’s condition, but that uncertainty left the family feeling very distressed.
We also found failings in how the Trust investigated what happened. The detailed investigation started almost four months after the incident.
The Trust should have reported it as a serious incident within two days and completed the investigation within 60 days. This uncertainty around the investigation made Miss C’s distress worse.
Putting things right
We said the Trust should acknowledge the issues with its policy and explain how it will offer sweeps on time and in line with national guidance.
We also said the Trust should explain how it will carry out serious incident investigations in line with national guidance and tell parents about the investigation.
We recommended the Trust pay Miss C compensation for how its failings affected her.