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Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.1258/01-02
Complaint against Salford Royal Hospital NHS Trust and the Central Manchester and Manchester Children’s University Hospital’s NHS Trust
Summary of Case
Mrs T attended Hope Hospital, Salford to have her baby delivered. She had given birth to her first child a year before, by emergency caesarean section. The consultant obstetrician told Mrs T that there was no reason why she would not be able to have a normal vaginal delivery, and did not warn her of any attendant risks. However, during the confinement, Mrs T’s uterus ruptured, thereby depriving her baby daughter of oxygen, and her baby died of consequential brain damage a few days later. Mr and Mrs T complained to the Salford Trust about the quality of care offered by the medical and midwifery staff but were dissatisfied with the explanations provided. They also asked whether any of their daughter’s organs had been retained following the post mortem. The Salford Trust told them that wafer thin samples of tissue may have been retained for research purposes. However, subsequently, the Manchester Children’s Trust, which had undertaken the post mortem, told Mr and Mrs T that their daughter’s brain had been removed for further examination and disposed of via their clinical incineration process. Mr and Mrs T then requested an independent review (IR) but this was refused. They complained to the Ombudsman that Mrs T should have been warned of the risks associated with having a normal vaginal delivery, that midwifery and medical care fell below acceptable standards, that bereavement counselling was not offered until 22 months after their daughter’s death, and that the handling of her request for an IR was unsatisfactory. Mr and Mrs T also complained that their daughter’s brain was retained and destroyed without their consent.
Findings
The Ombudsman, who was assisted by three independent professional assessors, found that it was reasonable for Mrs T to have been offered a normal vaginal delivery and, at that time, it was normal for obstetricians not to mention the very small possibility of risk involved. However, she was highly critical of the Salford Trust’s failure to seek urgent medical help and the decision by midwives to prescribe a drug, syntocinon, which was contraindicated in women who had had previous caesarean births, and against ward guidelines. She also criticised weak management control and found it regrettable that the Trust did not offer Mr and Mrs T any form of bereavement counselling until nearly two years after their daughter’s death. The Ombudsman criticised the Salford Trust’s handling of Mr and Mrs T’s complaint and found that the Trust had failed to be open and honest with them about the gross failures evident in this case. She described the clinical advice to the convenor as flawed and unsound and considered that the convenor should have sought advice from a demonstrably more independent source. There were also unnecessary delays. The Ombudsman also found that the Salford Trust failed to advise Mr and Mrs T of the likelihood that their daughter’s brain would be removed at the post mortem and then misled them as to what might actually have happened. She also criticised both Trusts for the lack of effective liaison over the post mortem.
Remedy
Both Trusts accepted the criticisms made in the Ombudsman’s report and apologised to Mr and Mrs T for the shortcomings identified. The Salford Trust said that they had now adopted a fresh approach to investigating complaints and had introduced changes to improve effective management control in the relevant directorates. They had also introduced new Maternity Unit Clinical Guidelines – including a protocol to deal with managing the labour of women with uterine scars – and will develop a protocol to ensure that women with previous caesarean sections are advised of the risks associated with vaginal delivery. They agreed to undertake an investigation into the senior midwife’s actions and to refer her to the National Midwifery Council, and gave an assurance that procedures were now in place to ensure that parents were fully informed when discussing post mortems. The Manchester Children’s Trust also advised the Ombudsman that it is now not routine practice to remove organs from a body without specific agreement from relatives and that they have introduced a new standard operating procedure on the post mortem examination of neonatal, postnatal and child deaths.
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