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Annual Report of the Ombudsman 2003

Chapter 3 - Midland Health Board - Communication Difficulties in Relation to Stillbirth

Midland Health Board

Communication Difficulties in Relation to Stillbirth

I received a complaint from a couple against the Midland Health Board (MHB) in relation to the treatment they received following the stillbirth of their baby daughter. The complaint related, mainly, to the lack of communication which the couple experienced following their request for information about the possible causes of the stillbirth, and difficulties which they experienced in obtaining follow-up appointments with the attending Consultant Obstetrician. The couple also complained that they encountered delays with regard to the Health Board's handling of their subsequent written complaint. The events complained of generated considerable frustration for them. Given that it was ten months since their baby daughter had died, they needed the information in order to help them advance through the grieving process and give consideration to any implications for possible future pregnancies.

I contacted the Board outlining the details of the case and was advised that it had not been possible, from a medical point of view, for the Consultant Obstetrician to give exact answers to the questions raised by the couple. He had spoken with them following the receipt of the post mortem results, but could not indicate a possible or likely cause of death. The Board advised me that, in the circumstances, it proposed to hold a Critical Incident Review in relation to the case in the hope that this might establish the cause of the baby's death, and whether there were implications for future pregnancies.

The review was facilitated by an expert in the field from outside the Board's area in collaboration with the Board's Risk Management Team, Consultants, Doctors, Nurses, Managers and Administrators, and involved a detailed medical investigation of all the circumstances surrounding the treatment of the mother during and after her pregnancy. This review included a set of recommendations. The Review Group held the view that this tragedy could not have been detected or prevented. It also confirmed, from the available information, that there was no clinical indication that such an event was likely to recur.

It is very difficult for a bereaved couple who have experienced stillbirth to consider the issue of future pregnancy. Such difficulty is compounded if there is a perceived lack of information or co-operation on the part of hospital or health board staff. In this particular case, I was encouraged by the Board's decision to hold a Critical Incident Review in relation to the circumstances surrounding this baby's death. I felt that this was a positive step in attempting to identify when and how the stillbirth happened and to give some reassurance and hope to the bereaved couple. I was further encouraged to note that the Review Group had identified a number of ways in which the Board's Stillbirth Policy could be significantly improved and made a series of recommendations in this regard. These reviews have the added advantage in that, in addition to dealing with the individual incident, systemic weaknesses can be identified and steps taken to ensure that similar incidents do not recur. The Board also produced and published a Bereavement Booklet which is to be made available throughout other health board areas.

I also received a somewhat similar complaint from a mother in the North Eastern Health Board (NEHB) area who had given birth to a stillborn baby. She had complained of an uncomfortable rash throughout her pregnancy and was referred to a Consultant Dermatologist. Following the stillbirth the woman became convinced that the rash which she had suffered throughout the pregnancy was Obstetric Cholestasis, a condition which only occurs during pregnancy and places the unborn baby at risk of stillbirth.

Under the Ombudsman Act I am specifically precluded from examining complaints against health boards about clinical decisions in the care or treatment of a patient. Consequently, the clinical aspects of the complaint were not matters which I could examine. However, I felt that it would have been useful if a Critical Incident Review, similar to that conducted by the MHB, had been carried out. I asked the NEHB to consider such a course of action in the event of future similar cases. In subsequent discussions with the Board I was encouraged to note that, since the time of the complaint to my Office, substantial progress has been made in relation to the holding of such reviews. The Board confirmed that the event complained of would be the subject of a review if it occurred today.

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