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Case ref:202300501
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Date:April 2024
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Body:Highland NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained about the actions taken and treatment provided by the board in respect of their pregnancy. C reported reduced fetal movements and was admitted to hospital with vaginal bleeding. The hospital discharged C as the vaginal bleeding settled and all clinical assessments undertaken were within normal parameters. However, C returned to hospital with significant vaginal bleeding and was diagnosed with placental abruption (a condition in which the placenta starts to come away from the inside of the womb wall). C’s baby was stillborn shortly after.
In C’s view, the board failed to take into account warning signs or carry out an appropriate assessment when they were admitted to hospital. C feels the outcome would had been different if their baby had been delivered at an earlier opportunity. The board acknowledged some failings in respect of delays caused by the hospital triage process, IT issues and signage. However, they concluded that these delays were unlikely to have made a difference to the outcome. The board were also satisfied that the broader treatment provided to C in respect of their pregnancy was appropriate.
We took independent advice from an adviser with an extensive background in obstetrics and gynaecology (a specialist in pregnancy, childbirth and the female reproductive system). We found that the board’s management of C’s pregnancy was reasonable and in line with relevant national guidance. There was no evidence that the board unreasonably failed to take any actions that they should have. Nor did it indicate that they unreasonably missed any warning signs pointing to this outcome. We noted that guidance prioritises the aim of prolonging the pregnancy in the absence of any signs of maternal or fetal compromise. In addition, we considered the staff’s actions to be reasonable when C presented at hospital. We agreed with the board’s conclusion that it was unlikely that the outcome would have been different had C not encountered the delays at the hospital. Therefore, we did not uphold C’s complaints.