Decision Report 201508165

Summary

Ms C was pregnant with twins when she was taken to Raigmore Maternity Unit by paramedics. She was found to be in premature labour and despite attempts to stop her contractions, her twins were delivered prematurely with very low birth weights. Ms C was 20 weeks pregnant at the time of the delivery and her twins did not survive. Ms C complained about the care and treatment that was provided to her and the twins. She also complained about the information and advice provided by the board on taking the babies away from the hospital. Ms C was concerned about the board's final response to her complaints as she felt this took a long time to be issued and contained a lot of mistakes.

After taking independent advice on this case from a midwife, an obstetrician, a neonatologist and a consultant physician, we did not uphold Ms C's complaints about the care and treatment. The advice we received was that the care was appropriate and no failings were identified in this regard. We also did not uphold her complaint about the information or advice that was given on taking the babies away from the hospital as this was considered to be reasonable in the circumstances. We did, however, make recommendations in this respect.

We upheld Ms C's complaint about the board's final response to her concerns. We found that while the response was issued within a reasonable timescale, there were a number of factual errors with details such as dates.

Recommendations

We recommended that the board:

• consider the introduction of a booklet for bereaved parents to assist staff in providing information;
• provide a specific apology for the error in the times of death noted on the removal forms;
• apologise for the issues identified with their final response; and
• review their process for fact-checking decisions before issue.