NHS Tayside has been ordered to apologise to a woman whose brain-damaged baby died nine days after being born.
Jim Martin, the Scottish public services ombudsman (SPSO), has ruled there had been ”an overall failure” by midwifery staff at Ninewells Hospital, although he cleared them of failing to diagnose quickly enough the condition that left the baby’s brain starved of oxygen.
His report said the woman, who has been identified only as Ms C, had told him she had been ”robbed of the chance to be a mother” and both she and her partner felt the death of their daughter in March 2010 had ”destroyed their lives”.
Mr Martin said: ”Ms C raised concerns that she had not received appropriate care and treatment when she attended hospital to deliver her baby. Complications arose during her labour and a prolapsed cord occurred.”
This is where the umbilical cord slips past the baby’s head and emerges through the cervix.
The ombudsman went on: ”Ms C subsequently underwent an emergency caesarean section. Her baby was born suffering from severe brain damage and died nine days later.
”My investigation established that during the advanced stages of her labour, a strong gush of green amniotic fluid occurred and Ms C was asked to get off the bed so that it could be changed.
”The distressing events that followed led Ms C to question the appropriateness of this advice.
”Ms C felt the concerns she expressed to a midwife during the advanced stages of her labour that something had moved downwards at the same time the large amounts of amniotic fluid soaked the bed and floor were ignored.
”Given the specific combination of circumstances surrounding Ms C’s labour, the available knowledge and the comments of my medical adviser, I upheld Ms C’s complaint that she was not listened to during her labour and that she was wrongly asked to get off the bed.”
The third aspect of the complaint was that Ms C said the prolapsed cord was not noticed straight away. She claimed that as a result her baby was starved of oxygen for a significant amount of time.
Mr Martin said he had considered all the evidence and took into account his medical adviser’s view that the prolapsed cord could not necessarily be predicted. The adviser also considered it speculative whether the condition could have been recognised earlier.
”I therefore did not uphold the complaint that the prolapsed cord could have been diagnosed much quicker,” he continued. However, Mr Martin noted that if the other failures had not occurred, Ms C and her baby may have had a better chance of avoiding what followed.
”I consider there was an overall failure by midwifery staff to ensure that Ms C received the correct level of care and treatment, which could have been reasonably expected given the combined set of circumstances she presented at the final stages of her labour.
”I made a number of recommendations to the board, namely that measures are taken to feed back the learning from this incident to all midwifery staff, to understand the importance of avoiding similar situations recurring and to issue Ms C with a formal written apology for the failures identified.”
A spokesman for NHS Tayside said: ”Tayside NHS Board accepts the recommendations in the SPSO’s report.
“Arrangements are already in place to ensure learning from this event is fed back to staff via supervision of midwifery processes and by means of direct communication with midwives.”