Decision Report 201405005

Summary

Mr C's daughter (Ms A) gave birth to a baby boy. Her pregnancy had been normal until the 32nd week when her blood pressure was noted to be high. She was monitored for pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine). Following the birth, Ms A suffered episodes of diarrhoea. This appeared to resolve and she was discharged home with her new baby. Midwives visited her at home over the following days and noted that she had had further episodes of sickness and diarrhoea, but again these were noted to have resolved.

Nine days after the birth, Ms A advised the attending midwife that she was unwell with tiredness, light-headedness, diarrhoea and vomiting. The midwife also recorded concerns about the baby's weight. Whilst arrangements were made for the baby to go back into hospital for checks, Ms A advised that she would attend her GP. Ms A became increasingly unwell and called Mr C for assistance. He took her to the Royal Alexandra Hospital where her condition continued to worsen. Ms A died of sepsis (infection in the blood) eleven days after giving birth to her son.

Mr C raised a number of complaints about the board's monitoring of Ms A's condition, the midwives' failure to note how ill Ms A was, and their failure to take Ms A back to hospital at the same time as her son. In each instance, we were satisfied that, based on the information available to staff at the time, there was no indication of a serious underlying condition. We acknowledged that the board had already highlighted some issues and had taken action to prevent these from happening again. We did not consider that these issues would have impacted on Ms A's care.