Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.2335/01-02
Complaint against the Luton and Dunstable Hospital NHS Trust
Summary of Case
In June 2000 Mrs E was admitted for an induction of labour. A CTG trace (a trace that monitors the foetal heart rate) was taken and was found to be abnormal. A repeat CTG was carried out around three hours later. This was reviewed by a specialist registrar, who perceived it to be normal. He decided to proceed with Mrs E’s labour and gave her a drug to induce labour at 6.00pm. A third CTG was taken at 7.20pm and, because of the poor results, a midwife arranged for Mrs E to be continuously monitored. The specialist registrar reviewed the third CTG at 8.50pm and attempted, but failed, to do an artificial rupture of the membrane at 10.15pm. Subsequently, he requested a further 30-minute CTG, noting that if it was normal Mrs E should be returned to the ward to be reviewed the following morning. The specialist registrar perceived this trace to be normal, and Mrs E was returned to the ward at 10.50pm. However, at 4.30am the following morning staff could not detect a foetal heartbeat; intra-uterine death was confirmed at 5.05am. Mrs E complained about the management of her labour.
Findings
The Ombudsman upheld Mrs E’s complaint. She found that the staff involved in Mrs E’s care had not reacted appropriately to the poor CTG results, which were a clear indication that the baby was in distress and needed to be delivered as a matter of urgency. The Ombudsman criticised the actions of the specialist registrar in not recognising that the CTG trace was grossly abnormal and for not attempting to deliver the baby quickly. The machine used for the CTGs printed out an interpretation of the trace; that should have minimised the risk of error. However, the specialist registrar ignored the information before him. The Ombudsman was also critical of the midwives involved in Mrs E’s care, because they did not question the decisions being made by the specialist registrar. Trust protocol in place at the time stated that if midwives had concerns about a decision they could refer the matter to a consultant, but that had not happened here. The Ombudsman said that the midwives had a responsibility to take action in response to the abnormal CTGs and the specialist registrar’s decisions.
Remedy
The Trust agreed to conduct an audit of CTGs to ensure that they were being interpreted correctly and to establish if more could be done to bring about improvements. The Trust also undertook to remind all midwives of their responsibilities and of the importance of following Trust protocols and policies. The Ombudsman was extremely concerned at the serious shortcomings in the specialist registrar’s practice. These concerns were taken up with his new employers, and the Ombudsman was satisfied that a great deal of time and effort had gone into improving his skills in interpreting CTG traces. Nevertheless, in recognition of the grave consequences of the specialist registrar’s actions, the Ombudsman invited the Trust to discuss with Mrs E and her partner whether an apology was sufficient redress and suggested that the Trust might wish to offer Mrs E some form of tangible compensation. The Trust agreed to this and apologised to Mrs E for the shortcomings identified.
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