Decision Report 201508528

Summary

Mr C complained about the care that was provided to his wife (Mrs A) at the Princess Royal Maternity Hospital when she was admitted for the induction of labour. Mrs A gave birth to a healthy baby. However, Mr C was concerned that Mrs A did not receive appropriate care prior to being moved to the labour ward. He considered that she was not properly assessed and that as a result, she did not have access to appropriate pain relief.

We took independent midwifery advice. While we found that the initial care Mrs A received was reasonable, the advice we obtained was that following this, there was no evidence that assessments were carried out in line with the relevant guidance, particularly the board's own Latent Phase of Labour guideline. The adviser considered that there had been a failure to recognise that Mrs A had progressed into established labour and that she had missed out on the appropriate level of monitoring as a result. The advice we received also highlighted some issues around the way that Mrs A's pain was managed. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C and Mrs A for the failures identified by this investigation;
• draw the comments of the adviser regarding monitoring to the attention of relevant staff for reflection;
• raise awareness of the Latent Phase of Labour guidelines to ensure that they are applied appropriately; and
• draw the comments of the adviser on planning pain relief alongside the patient to the attention of the relevant staff.