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Selected Investigations Completed October 1997 - March 1998 > Part II, Case no. E.1633/96-97

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Case No. E.1633/96-97 - Uninformative and distressing meeting to discuss a complaint; and inappropriate response by Trust to the report of an independent review (IR) panel

Matters considered: A meeting with the trust was uninformative and distressing for the complainant; chief executive's response to the findings and recommendations of the panel was inappropriate and insensitive

Complaint against: Preston Acute Hospitals NHS Trust

Complaint as put by Mrs X

1. The account of the complaint provided by Mrs X was that on 9 February 1996 she gave birth to a baby girl at Sharoe Green Hospital (the hospital), Preston. Baby X died of respiratory problems later the same day. On 2 May Mr and Mrs X complained to Preston Acute Hospitals NHS Trust (the Trust), which manages the hospital, about the care and treatment Mrs X and her baby received before and after the birth. The Trust replied on 19 June and offered Mr and Mrs X a meeting at which they said they would give further explanation. At the meeting, which took place on 27 June, the Trust were unable to answer Mr and Mrs X's questions or provide any further information about the complaint. The Trust wrote again on 23 July, but Mr and Mrs X remained dissatisfied. On 22 August the Trust's convener agreed to set up an independent review (IR) panel to consider the complaint. The report of the IR panel was sent to the Trust on 5 December; and on 3 January 1997 the chief executive of the Trust wrote to Mr and Mrs X that he had some reservations about the IR panel's deliberations and conclusions and had decided not to accept some of their findings and recommendations.

2. The terms of reference of the IR panel were 'the management of the birth of baby X and the subsequent care received by mother and baby'.

3. The complaints subject to my investigation were that:

1. the meeting with the Trust on 27 June was uninformative and distressing for Mr and Mrs X; and
2. the chief executive's response to the findings and recommendations of the IR panel was inappropriate and insensitive.

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Investigation

4. The statement of complaint for my investigation was issued on 16 April 1997. I obtained the comments of the Trust; and relevant papers, including Mrs X's and baby X's medical and nursing records, were examined. My investigating staff took evidence from Mr and Mrs X, the chief officer of Chorley and South Ribble Community Health Council (the CHC officer), Trust staff and the convener, the chairman and two of the clinical assessors to the IR panel. At the beginning of my investigation it was explained to Mrs X that I would need to examine the circumstances so as to decide whether any part of the complaint concerned action taken solely in the exercise of clinical judgment, which at the time of the events complained about was outside my statutory jurisdiction.

Complaint (a)
Meeting was uninformative and distressing

Evidence in support of the complaint

5. Mrs X told my investigator that she had not requested the meeting with the Trust's director of midwifery and the complaints officer on 27 June; but, as the Trust had offered it, she did not want to appear unco-operative by refusing to attend. However, she had found the meeting a waste of time. Neither the complaints officer nor the director of midwifery was able to add any further information to that which had been provided by the chief executive in his letter of 19 June (see paragraph 7). All they did was take a note of the questions Mr and Mrs X raised and undertake to investigate them. Mrs X said she had found the meeting, which lasted for about an hour and a half, a frustrating and ultimately very distressing experience. She thought it would have been more useful if the people involved during her labour, in particular the midwife who cared for her (the midwife), had been present so that she could have asked them questions.

6. The CHC officer said that she had accompanied Mr and Mrs X to the meeting, which she described as 'appalling'. The complaints officer did not appear to have interviewed the staff involved in the complaint before the meeting, and so was ill-equipped to answer Mr and Mrs X's questions. The meeting was chaired by the director of midwifery, who was insensitive and patronising towards Mr and Mrs X; the CHC officer was shocked by her defensive attitude. The CHC officer said she thought the Trust staff would have been happier if she had not been there because she challenged them about why there was nobody present who could answer Mr and Mrs X's questions. The CHC officer said she had no recollection of telling the complaints officer before the meeting that Mrs X would not wish the midwife to be present (see paragraph 11).

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Documentary evidence

7. In his letter of 19 June to Mr and Mrs X, the chief executive wrote:

'I believe that further explanation may be beneficial. I would therefore suggest further discussion with our [director of midwifery]...'

'...[Mrs X] stated that the evidence of what happened is from the midwife from her verbal report to [the director of midwifery]. No documentation to confirm this for [Mr and Mrs X]. [The director of midwifery] could only state what has been reported by [the] midwife and state what "appeared" to have happened....'

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Evidence of the Trust

9. In the Trust's formal response of 1 May 1997 to my investigation the chief executive commented:

'The meeting was offered to [Mr and Mrs X] to further explain the findings on which the Trust's response of 19 June was based. Some new issues were raised that necessitated further investigation. [Mr and Mrs X] received detailed information on meconium, fetal distress, labour ward protocols and the effects of Pethidine as both an analgesia and potential respiratory depressant to the baby. [The director of midwifery] offered detailed technical information using obstetric text present at the time.

'We accept that the meeting was distressing for [Mr and Mrs X]. Due to the nature of the complaint this was distressing for all concerned. Each issue raised was dealt with in an appropriately sensitive manner.'

10. The director of nursing told my investigator that she acted as the Trust's complaints manager and maintained an overview of all complaints. She said the Trust liked to hold meetings with complainants, as they found it helpful to get people to talk about their complaints. The face to face personal contact was valued by complainants. The meeting on 27 June was never intended to be the final response to Mr and Mrs X: it was intended more as a way of expanding on the information the Trust had already provided and finding out what aspects of the complaint remained unanswered. It was not unusual for the Trust to hold more than one meeting with complainants. She thought Mr and Mrs X had assumed that the meeting would provide all the answers to their questions, and that was partly why they found it unsatisfactory. She said that she or the chief executive would have attended the meeting if Mr and Mrs X had asked for that. No consultant had been asked to attend because Mr and Mrs X had already met the consultant obstetrician to discuss Mrs X's obstetric care.

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11. The complaints officer said that before the meeting she asked the CHC officer whom Mr and Mrs X would like to be present. The CHC officer made it clear that Mrs X did not want the midwife at the meeting, and said the director of midwifery would be able to answer all their questions. The complaints officer was a qualified nurse but without any experience in midwifery, and she found the meeting very informative. The director of midwifery tried to give an explanation about each question asked and referred to text books, when necessary, to illustrate her point. If there was an issue which needed further clarification, the director of midwifery said the Trust would investigate and try to give the information required. Mr and Mrs X raised some questions which they had not asked before. She knew there were very few points on which Mr and Mrs X had been completely satisfied at the meeting; but she thought that it had been a useful way of finding out what their remaining concerns were. The complaints officer said that the CHC officer had been heavily involved in the discussion, but that she kept stressing points that Mr and Mrs X were well able to make for themselves. She thought the CHC officer had been aggressive and had not behaved in a very professional manner. The meeting had been extremely distressing for everyone involved.

12. The director of midwifery said that she had spoken to the midwife several times before meeting Mr and Mrs X and had obtained all the information she could from her. She had also spoken to the senior midwife who had been in charge of the delivery suite on the day of Mrs X's labour. The director of midwifery described the meeting as 'awful' because the Trust could do nothing to change what had happened; she said it was not helped by the CHC officer who changed the tone of the discussion by becoming aggressive both to the complaints officer and to her. The director of midwifery was the person at the meeting competent to answer clinical questions about the events; and she said it was difficult to explain to Mr and Mrs X and the CHC officer why there were no clear-cut answers to the questions they were asking. There could have been numerous reasons for the presence of meconium in Mrs X's amniotic fluid and for the dips in baby X's heartbeat during labour and, accordingly, different actions which the midwife could have taken. It was easier to give a more considered interpretation of events with the benefit of hindsight. She tried to use text books which were in the room to illustrate what she was saying to Mr and Mrs X. However, she thought that the CHC officer's antagonism towards her made it difficult for Mr and Mrs X to accept anything she said.

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Findings (a)

13. The chief executive offered Mr and Mrs X a meeting which his letter said would give 'further explanation' of the Trust's response to their complaint. However, in the course of this investigation the Trust have said that the meeting was never intended to be the final response to Mr and Mrs X but that it was a useful way of finding out about their remaining concerns. It is not surprising that, if they took the chief executive's invitation at face value, which they had every right to do, their expectations for the meeting were significantly different from those of Trust staff. I criticise the Trust for not being clearer about the purpose of the meeting.

14. Mrs X has said that she would have found the meeting more informative if staff involved in her labour, particularly the midwife, had been present. The complaints officer has said that the CHC officer told her specifically that Mrs X did not want the midwife to attend and that the director of midwifery would be able to answer all Mr and Mrs X's questions. The CHC officer can recall no such conversation and I have been unable to resolve this conflict of evidence. I believe the Trust acted in good faith in organising the meeting and that the director of midwifery did her best to provide Mr and Mrs X with the explanations they sought. However, given the seriousness and clinical nature of the complaint, and also that the meeting was held at the instigation of the chief executive, in my view the Trust should have considered strengthening the clinical and managerial representation of the meeting.

15. The chief executive has acknowledged that the meeting was distressing for all concerned. I accept that discussing the loss of their daughter would always be painful for Mr and Mrs X; but I think their distress was exacerbated by their belief that they had moved no closer to a resolution of their complaint. The meeting also seems to have been made more distressing by animosity between Trust staff and the CHC officer. Regardless of who prompted that, it is most unfortunate that the meeting deteriorated in such a way. I uphold the complaint that the meeting was uninformative and distressing to the extent that it did not meet the expectations that Mr and Mrs X had been given.

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Complaint (b)
Chief executive's response to the IR panel's report was inappropriate and insensitive

Evidence in support of the complaint

16. Mr and Mrs X told my investigator that when they asked for an IR panel they thought they would get a genuinely independent review of their complaint. However, they had found the whole process ultimately frustrating. When they received the report they had to read it several times before they understood what it was saying. They thought there were too many unanswered questions and that some of the recommendations contradicted the findings. However, their disappointment with the report was nothing in comparison to their disgust at the chief executive's letter of 3 January 1997. They had been unhappy with most of his previous letters, but the letter of 3 January seemed particularly insincere. They did not like the way he pronounced on clinical matters as though he was an expert and would have preferred it if he had said at the start of the letter that it had been written in conjunction with medical and nursing staff. Mr and Mrs X thought the chief executive's letter implied that they were liars. They did not agree with any of the chief executive's comments on the IR panel's findings and recommendations.

17. After they received the letter, the chief executive rang them to ask if he could come to their home with the nursing director to discuss their complaint further. Mr and Mrs X declined the offer. They felt it would have been easy for him to come to their home to ease his conscience and look after his Trust's best interests; but they would have had to go through the painful process of discussing baby X's death again. Mr and Mrs X said that they could not understand how the Trust had been allowed to get away with not answering their questions for so long. In her letter to me Mrs X wrote:

'...This seems to me to show the NHS complaints procedure as at best a waste of time and money and at worst a distressing and prolonged procedure....'

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National requirements

19. On 1 April 1996 new national procedures for handling complaints in the NHS were introduced. The statutory directions to NHS trusts and other NHS bodies on the operation of the procedures include, on the response of a trust to a report of an IR panel:

'28.(1) A letter reporting the outcome of the trust['s] consideration of the [IR] panel's report shall be sent to the complainant by the chief executive within such time as is reasonable stating -

1. any action which the trust proposes to take in relation to any suggestions in the report; and
2. where it is decided that no action should be taken on any suggestion, the reasons for that decision.'

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20. The new national procedures were based on a report ('Being heard') which was published in May 1994. It included, at paragraph 295:

'The purpose of offering [an independent review] procedure is to offer a more formal degree of impartiality than can be achieved if an unresolved complaint is reconsidered by a part or agent of the organisation complained against.'

21. The report of the IR panel was sent by its chair to Mr and Mrs X and the Trust on 5 December 1996; the Trust also received summary notes of the discussions that took place with those interviewed by the panel. The report was shown to the midwife who made handwritten notes on her copy, disagreeing with many of the points made in the report. The director of nursing then drafted a response to the findings of the IR panel. On 18 December the convener wrote to the chair of the IR panel as follows:

'...unfortunately I have to tell you that the detail of the report and the recommendations have caused a great deal of consternation within the Trust.

'[The midwife] is, I am told, extremely disappointed with the findings and a number of the recommendations incorporated in the report are not accepted by the Officers of the Trust.

'...[the director of nursing] has prepared a response to the findings of the review and I enclose herewith the response to which I refer.

'...This may well result in [Mr and Mrs X] wishing to take further action. Furthermore, it may be that [the midwife] will feel so aggrieved at what she might see as a slur on her professional integrity etc, that she too may decide to take some action (she considers that some of the Panel's findings were based on unconfirmed evidence and the Panel chose not to believe her account)....'

'...However, as you will see from this letter, I have some reservations about the panel's deliberations and the conclusions they have made....'

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Evidence of the Trust

24. In the Trust's formal response of 1 May 1997 to my investigation, the chief executive wrote:

'The response dated 3 January 1997 clearly explained the Trust's position on the [IR panel's] findings. We feel that it was appropriate to make this response and do not accept that the response was insensitive. This had been a lengthy and detailed complaint and it was considered appropriate to address the issues in a direct manner.'

26. The director of nursing said she thought the report of the IR panel was very poor, and that the findings were not substantiated by the evidence. She told the convener, and discussed her reservations with the chief executive, the midwives concerned and the clinical director of obstetrics and gynaecology. She was aware that writing to Mr and Mrs X would be very difficult and she spent a long time drafting the letter in the most sympathetic manner possible. However, she felt that the Trust had to be very clear and factual in their response because the IR panel's report had been so unsatisfactory. She realised that the letter was bound to upset Mr and Mrs X; but in the circumstances she felt it was appropriate. She thought it would have been a good idea to meet Mr and Mrs X again, but they declined the offer of a meeting. She believed the IR had been a very unsatisfactory process all round, and that it would not have helped Mr and Mrs X come to terms with the loss of their baby.

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Evidence of the IR panel

27. The convener said that Mr and Mrs X's request for an IR panel was one of the first the Trust had received. At that time, they were still feeling their way as regards the running of IR panels. He said that if he had to do it again he would spend more time discussing the issues with the clinical assessors before interviewing the complainants or Trust staff involved. After the IR panel hearing, the panel members discussed among themselves what preliminary views they had reached. They realised that the evidence provided by Mr X and the midwife was contradictory but they agreed that, on the day, the more credible account of the events of 9 February was that given by Mr X. He thought some of the points in the chief executive's letter of 3 January to Mr and Mrs X might have been valid—the subject had been complicated and difficult to judge—but he stood by the report and was disappointed that the Trust had not simply accepted the panel's findings, learned their lesson, and laid the matter to rest.

28. The chair said she was not medically qualified, so she had relied upon the advice given to her by the clinical assessors. After the panel had received the clinical assessors' reports they weighed up all the evidence given by those who attended the hearing and agreed that, on balance, the most credible account of what had happened on 9 February had been given by Mr X. She said the panel members had had to base their opinion on the evidence they had heard and the impressions they had gained.

29. In her report to the IR panel the first clinical assessor wrote 'multiple reports by different people of the same events will naturally give variation attributable to the differing view points.' She set out Mr X's evidence and that of the midwife and did not choose between them. She summarised by saying that she considered 'the decisions made at the time were reasonable ones'. The second clinical assessor told my investigator that after the panel hearing he telephoned Mr X at home to clarify one aspect of the evidence he had given to the panel. Mr X was very clear and consistent in his remarks relating to the events of 9 February; and the second clinical assessor believed he was not making them up. The third clinical assessor told my investigator that she thought both Mr X and the midwife had given equally plausible accounts of the events of 9 February and that she could not have chosen between them.

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Findings (b)

30. The IR panel report found that there had been failures in the care provided to Mrs X while she was in labour. Several of its findings were based on the evidence given by Mr X at the IR panel hearing and were strongly disputed by the midwife. The chief executive thought the panel's report was wrong in several respects; that it had not addressed all Mr and Mrs X's concerns; and that insufficient account had been taken of the conclusions reached by the clinical assessors. The director of nursing felt that the findings were unsupported by the evidence and she could not understand why they had chosen to ignore the testimony of the midwife. The chief executive and the director of nursing subsequently took their concerns to the Trust board, which concluded that the Trust could not support the findings of the IR panel and agreed the response to be conveyed in the chief executive's letter to Mr and Mrs X of 3 January.

31. The statutory directions (paragraph 19) required the chief executive to write to Mr and Mrs X about the action the Trust proposed to take on the recommendations in the panel's report, and, in any cases where he proposed not to implement the recommendation, to explain why. The chief executive's letter of 3 January fulfilled that requirement, but went much further: it explicitly took issue with many of the panel's findings. In doing so, it destroyed the purpose of the IR panel process, which had been described as 'to offer a more formal degree of impartiality than can be achieved if the complaint is reconsidered by the organisation complained against' (paragraph 20). I am not surprised that Mr and Mrs X considered that the chief executive's letter called into question the credibility of the system of which the IR panel was part.

32. Under the procedure, the chief executive had discretion not to implement some of the panel's recommendations, as long as he told the complainant why. In my view, he would have been wiser to have confined his correspondence with the complainant to the recommendations, despite his misgivings about the panel's findings. It is not for me to judge whether the panel or the Trust were right in the matters on which they disagreed: it was undoubtedly a complex complaint. Although I appreciate that the chief executive wanted to protect the interests of his staff and the Trust, there were other and better ways of doing this. In my judgment, the action taken by the chief executive in his letter of 3 January contravened the spirit of the IR panel stage of the procedure. I uphold the complaint.

Conclusion

33. I have set out my findings in paragraphs 13-15 and 30-32. The Trust have asked me to convey through this report—as I do—their apologies to Mrs X for the shortcomings I have identified.

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Appendix to E.1633/96-97

Details of findings and recommendations by the IR panel, the Trust's responses, and other relevant evidence

Section (a) of each paragraph below is the IR panel's finding or recommendation and section (b) is the Trust's response in the chief executive's letter of 3 January 1997.

FINDINGS

1. (a) In the age of high technology, we find it difficult to accept that a continuous paper trace was not taken during [Mrs X's] total period in labour. The provision of such a trace would have provided vital ongoing information, beneficial to the treatment of both baby and mother.

(b) The Trust does not accept that a continuous paper CTG trace should have been taken throughout labour. We do not believe that there were indications for [Mrs X] to have been continuously monitored. Continuous monitoring without specific indication is not consistent with good obstetric practice. [The midwife's] stated intention during the early part of the morning was to establish labour by encouraging movement ([Mrs X] was sitting in the rocking chair after [the midwife] had accompanied her to the toilet) and attachment to a monitor would have been inconsistent with this intention.

2. (a) We are satisfied that [Mr X] observed several drops in the fetal heartbeat during the period 8.00am to 10.00am, at a time when the paper trace was not functioning (but it must be remembered that the monitor of the fetal heart is the professional—midwife or doctor—who would interpret this information) [sic].

(b) The tracing evidence supports

[the midwife's] statements that the CTG monitor was not attached continuously and that intermittent readings only were taken. There would, therefore, be no digital readout for [Mr X] to see. Moreover, had the monitor been attached continuously, there would have been no reason to make intermittent recordings. We feel that it is also extremely unlikely that, had [Mrs X] been attached to the monitor, such dips in the fetal heartbeat would not have been noticed by other members of staff at the central monitoring station or in any other of the rooms in the delivery suite (where all monitors can be seen on screen). The monitors are programmed to alarm at heart rates of 120 or below and all staff are well used to responding to alarms wherever they may occur. No such alarm was noticed by any member of staff at any time.

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3. (a) The drop in the fetal heartbeat was drawn to the attention of [the midwife] on her entering the delivery room prior to carrying out the vaginal examination and the rupturing of the membranes. This information from [Mr X] was not recorded on [Mrs X's] notes.

(b) The Trust accepts [the midwife's] statement that the drop in fetal heartbeat was noted by her after she had performed a vaginal examination at 10.00am.

4. (a) The rupturing of the membranes revealed a quantity of old meconium, flecked with new meconium. It would appear that [the midwife] omitted to connect the information provided by [Mr X] with her own clinical findings.

(b) Because of our conclusion above, the Trust does not accept that there was a failure of omission on [the part of the midwife].

5. (a) We accept that there were different interpretations as to the amount of meconium observed at that examination. We find that meconium was present in a sufficient amount, which having regard to the information available, should have encouraged [the midwife] to seek additional medical advice at that stage. This was a critical time.

(b) The Trust accepts that there were different interpretations as to the amount of meconium observed at the rupturing of the membranes. The Trust is of the view that [the midwife] acted on her findings by attaching a fetal scalp electrode and by changing [Mrs X's] position. The fetal scalp electrode was inoperable and so the abdominal transducer was attached.

6. (a) There was an absence of written confirmation that [medical] advice was obtained. The director of midwifery confirmed that [the midwife] was very precise on the keeping of appropriate records.

(b) The Trust accepts this finding.

7. (a) The involvement of [the obstetrics and gynaecology registrar (the registrar)] in this matter was minimal in that on first seeing [Mrs X] at around 11.05am, the birth of [baby X] was thought to be imminent and therefore the fetal blood sampling, previously considered, was felt to be unnecessary. [The registrar] was responsible at the time for another patient in labour and did not recall anything being said to her which necessitated her urgent intervention.

(b) The Trust acknowledges that [the registrar's] involvement was minimal. The Trust is of the view that, from the evidence to hand, urgent intervention was not thought to be required.

8. (a) The birth of [baby X], although delayed, proceeded to a normal delivery and the airways were cleaned on the perineum. There were no clinical reasons relayed to [the registrar] to suggest that a normal vaginal birth was not appropriate. There was heavy meconium staining present at birth.

(b) The Trust does not accept that the birth of [baby X] was delayed in any way. The Trust accepts that there were no clinical reasons relayed to [the registrar] to suggest that a vaginal delivery was not appropriate and the Trust believes that all the clinical facts were available to [the registrar] throughout the labour.

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9. (a) [Baby X] appeared initially to be responding, although a little sleepy, but [the senior house officer, paediatrics, (the SHO)] appeared more concerned than others present as to [baby X's] lack of progress and of the occasional grunting noises which had manifested themselves.

(b) The Trust sees no evidence that the midwives present were not as concerned as [the SHO] regarding [baby X]. We note that in [the midwife's] original statement she commented that the baby may be cold, took the rectal temperature and encouraged wrapping and heat application. [The midwife] took [baby X] to the Neonatal Unit as soon as [the SHO] made the decision to transfer.

10. (a) [The SHO], although having previous experience in paediatrics, had only been at the hospital for two days. He was not as familiar as his colleagues were with the transport procedure to the Neonatal Unit and therefore there was some delay in the actual transfer.

(b) The Trust accepts that [the SHO] was new to the Trust but does not accept that there was a delay in the transfer taking place, once the decision had been made.

11. (a) The treatment afforded to [baby X] in the Neonatal Unit and the support and respect for the parents was both caring and of a high standard.

12. (a) It was regretted that [baby X] did not recover and died on 9 February 1996 at 7.55pm.

13. (a) The cause of death was 'Extremely Severe Meconium Aspiration'. It was impossible to say when the meconium aspiration took place.

14. (a) We are satisfied that, on the information available, earlier diagnosis of meconium aspiration on 9 February would unfortunately not have led to a different outcome.

15. (a) We share [Mr and Mrs X's] concerns about the baby's missing original notes (although the IR panel did have photocopies of the notes).

16. (a) The various doctors and midwives throughout this matter acted in good faith and in a manner which they individually believed to be in the best interests of the mother and child.

17. (a) [Mr and Mrs X] showed considerable courage in presenting their views during what must have been a distressing experience for both of them.

17. (b) The Trust accepts the remaining findings.

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RECOMMENDATIONS

1. (a) Induction and support into hospital procedures and its environment for new medical staff is essential. They should have not only a written plan but there should also be a personal commitment from all staff to assist them during this process.

(b) The Trust accepts this recommendation and believes that the well established induction programmes cover the relevant issues. I will, however, be asking the Clinical Directors of Obstetrics and Gynaecology and Paediatrics to ensure that junior staff are made aware of how to manage issues across the interface of their respective departments.

2. (a) The Delivery Suite staff need to work as a team rather than separate professional groups and information should be shared between them.

(b) The Trust accepts this recommendation and feels that staff are committed to this way of working.

3. (a) Formal multi-disciplinary audits should be commissioned to discuss similar incidents soon after they occur and any recommendations following from that audit should be implemented.

(b) The Trust accepts this recommendation and I will be asking the Clinical Director for Obstetrics and Gynaecology to ensure that arrangements are in place for such audits to take place.

4. (a) Training sessions on communication skills should be made available to all staff in the midwifery and obstetrics and gynaecology departments.

(b) The Trust accepts that training in communication skills is important for all staff. Such training is available via the Trust's contract with [another trust's] training department and with [a university] as well as through our own internal training resources.

5. (a) The obtaining of information for audit purposes should be dealt with in a sensitive manner and regard given in difficult cases to the genuine feelings of members of staff.

(b) The Trust accepts this recommendation and I will be asking the Clinical Director to ensure the requisite sensitivity is shown while having due regard to the rigour of the audit.

6. (a) Supervisors of midwives should be available to gather accurate information promptly when an unexpected incident occurs. The supervisor in charge of the Delivery Suite should take a more active role in overseeing all that is going on in the individual rooms.

(b) The supervisor in charge of the Delivery Suite was present at the delivery—the Trust does not accept that a more active role is required.

7. (a) The hospital should make full use of the technology available and continued training for all its staff on the use of and the information obtainable from such technology should be undertaken.

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(b) The Trust believes its current use of technology is appropriate and consistent with good practice and agrees that continuous training is necessary.

8. (a) When a decision is taken to monitor electronically, the monitoring by way of the transducers or, where appropriate, use of fetal scalp electrodes, should be continuous and a permanent paper trace be kept of the monitoring process.

(b) The Trust accepts this recommendation when there is an indication for continuous monitoring but does not accept that monitoring should be continuous in every case.

9. (a) Although we acknowledge that the person supervising care is responsible for interpreting the trace, it might be helpful to examine whether the equipment at the central monitor station could be programmed so that extreme peaks and troughs of readings would be brought immediately to the attention of the observer to prompt appropriate action.

(b) The monitors are already programmed in this way.

10. (a) Information provided from patients or their relatives should be acted upon insofar as it may be material to ongoing care and such information should be noted on the patient's record.

(b) The Trust accepts this recommendation and recognises that partners play an important role in care.

11. (a) Compliance with the regulations of UKCC, including in particular record keeping, should be maintained at all times. The adherence to these regulations could prevent disputes arising in the future and also be used by staff to justify their clinical decisions.

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12. (a) The maintenance of full records is absolutely vital in all cases. Those records should be full and contemporaneous.

13. (a) The procedures for the management and security of case notes should be reviewed, to safeguard vital clinical information.

13. (b) The Trust accepts the remaining recommendations.

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Last updated: 24 January 2006