Decision Report 201601265

Summary

Mrs C complained about the care and treatment she received when she gave birth at Dumfries and Galloway Royal Infirmary. In particular, she said that a pessary used to induce labour was left in too long, she was unable to use the birthing pool and a tear she suffered was not effectively repaired.

We took independent midwifery advice and found that overall, Mrs C's labour and birth had been conducted reasonably. The pessary had been used appropriately and was removed as labour progressed. Stitching of the tear she sustained was completed quickly and though it was recognised that sutures could become loose, Mrs C was referred to an obstetrician as required.

However, it was noted that Mrs C either did not receive or did not understand information given about anaesthetic and how its use had repercussions with regard to the use of the birthing pool. Furthermore the clinical records, which were not of the standard required by current guidance, lacked information. For these reasons, we upheld Mrs C's complaint.

Mrs C also complained about her aftercare. However, we found no evidence to show that this had not been reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failures identified in this investigation; and
• ensure that relevant nursing staff are reminded of their obligations with regard to guidance on record-keeping.