NHS Highland’s chief executive apologised yesterday for failures in the care of a woman who lost her baby during birth.
A watchdog upheld a complaint about the care she had received at the north’s flagship hospital, Raigmore.
The Scottish Public Services Ombudsman also found the woman – named only as Ms A – had not been given a proper chance to decide if she wanted a caesarian section.
The baby was stillborn after her shoulders became stuck in her mother’s pelvis – a complication known as shoulder dystocia – which also happened during the birth of Ms A’s first two children.
A Highland politician and a national patient group last night described the failings as “appalling”. And they said lessons must be learned from such a “tragic” incident.
The health board apologised yesterday, through chief executive Elaine Mead, for the “lack of appropriate care and advice” given to the patient during her pregnancy in 2011 and said improvements were being made.
Scottish Public Services Ombudsman Jim Martin said: “My main criticism of the health board is the lack of discussion of birthing options with the mother and, in my report, I acknowledge the trauma and loss that she has suffered.”
The complaint was brought on behalf of the mother by an advice worker, who complained that no extra scans or checks had been carried out on Ms A during her pregnancy, despite being told her baby was big.
She also pointed out that the size of the mum-to-be’s baby and her medical history meant different birth plans should have been in place.
It was also feared that staff did not have her previous clinical notes and did not know about previous childbirth complications.
Mr Martin said: “I concluded that reasonable reviews were carried out after Ms A was admitted and that the emergency situation of shoulder dystocia was appropriately managed, in that reasonable manoeuvres were attempted after this was diagnosed at the time of delivery.
“Ms A’s previous history of shoulder dystocia had been documented when she was admitted to the antenatal ward.
“However, I was concerned that there was no clear evidence to show that the midwife on the labour ward was clearly aware of Ms A’s previous complications.” He added that it would have been good practice for the antenatal ward midwife to have included this in the handover note to the labour ward midwife. But he said this was unlikely to have changed the outcome.
Mr Martin also said he was not satisfied that staff at the hospital had followed the guidelines and discussed the risks of shoulder dystocia and the birthing options with Ms A.
“Although it is not mandatory to recommend elective caesarian section routinely, there was no evidence to support that Ms A was given the opportunity to make an informed choice about birthing options,” he said.
“It is not possible for me to say what options Ms A would have considered had these discussions taken place.
“However, I am clear that she was not given the opportunity to make a considered choice in relation to birthing options and I am critical of this.”
The ombudsman upheld the complaint and said NHS Highland should review its guidance to staff on the antenatal management of women to ensure that the risks of recurrent shoulder dystocia are discussed with expectant mothers, together with birthing options.
And he said the antenatal midwife who looked after Ms A should be told about the importance of including previous history of this condition in the handover note to the labour midwife.
Ms A did not wish to comment.