"Serious concerns about protocol in the labour ward"

About: Queen Elizabeth Hospital / Maternity

(as the patient),

We are writing to bring to your attention the appalling and frightening experience we had in Queen Elizabeth Hospital Woolwich in the days leading up to the birth of our baby. In retrospect we believe that we were lucky that our baby was born safely because there were a number of ways in which care was neglected which could have led to very serious consequences.

We are writing to set out what happened, so that we can receive an apology, but just as important, so that the Trust will investigate our complaint and be able to assure us that this will never happen again to anyone else.

The sequence of events is as follows:

Thursday

My waters had broken at 7.30pm the day before, and contractions started. We were up all night and early on Thursday morning we phoned the Princess Royal Hospital, where I had attended ante-natal appointments and had planned to have the baby. I had received good care there and we knew the midwives. We asked whether we could come in and were told there were no beds. They suggested we tried the Queen Elizabeth hospital as it is affiliated, but we tried Lewisham first because it is nearer to where we live, and we have no car. Lewisham too said they had no beds. We phoned back to the Princess Royal and spoke to a midwife we knew who phoned ahead to the Queen Elizabeth to arrange for us to go in and gave us the name of someone there to ask for. At this point my contractions were coming every 5 minutes.

When we arrived at the Queen Elizabeth we asked for the midwife we had been told to ask for but she was nowhere to be found. We were told that I could be examined with a speculum but due to the risk of infection I would have to be induced within 12 hours. I was examined in triage and found to be 3cm dilated. I was not examined again to check dilation until Saturday morning. I was not taken to the labour ward until Saturday after being in labour for 63 hours)

After triage I was left in the corridor for five hours (I was told to walk about) before a midwife found me a room – but not on the labour ward.

We were repeatedly told that I could not be examined again with a speculum because we were not on the labour ward and the protocol dictated that the examination could not be done on an ordinary ward. The midwives who saw us appeared to be very nervous about following protocols even though we were worried and I was in a lot of pain.

I stayed in a bath for 7 hours and we saw no-one, and no-one checked on me during this time. We were in a bathroom being used as the cleaner’s cupboard and my partner had to move everything out of it first to make room.

Friday

On Friday morning there was a staff change in shifts and we asked the next midwife why I was not being treated as a priority, as I was having long (the midwife agreed they were “unusually long”) contractions and was in great discomfort, with no pain relief. Even though my contractions were not every three minutes I had been left alone in labour for 24 hours. We were worried that the contractions were not progressing to be more frequent. Other women appeared to be given priority, perhaps because they were making more noise.

Towards the end of the shift, about 6pm on Friday, the midwife turned me over and looked at my stomach where there was a blatant second bulge. She inserted a catheter into my bladder and 900ml of liquid came out.

This midwife had tried to get us onto the labour ward but when the new shift came on on Friday night we had to work all over again to try to get onto the labour ward.

The next midwife did try to examine me with a speculum but couldn’t manage it, so proceeded as if it was still 3cm. She did, however, bring some gas and air.

On Friday morning my partner asked someone on the new shift who was going through paperwork to come to see me. My partner thought she was a midwife but she was in fact a doctor. The doctor felt my stomach and thought the baby was lying back to back, but nothing more was done.

During the night a fitball was brought in and the midwife suggested I should sit on it to speed things up. I was very weak and my partner had to help to hold her on it.

Meanwhile there were negative dips in the baby’s heart rate on the monitor and the midwife kept resetting it thinking it was an error. When she discovered it was not an error she told us that they were “not frequent enough to be a problem”. We were very concerned.

Saturday

Early on Saturday morning at the end of the shift the midwife made some phone calls to try to get us to the labour ward, without success.

The shift changed over and the new midwife, who seemed more experienced or more senior, was not happy with our situation. I was still not examined to see how dilated I was. I had been asking for an epidural by now for some time.

The midwife was told that there was a room available finally allocated to me but there was no midwife available there so we had to stay where we were. At that point the midwife went to get a doctor.

The doctor did a hand check but didn’t find the baby’s head because he was looking too far up, and he went to get some scanning equipment from elsewhere, which he used and saw that the baby’s head was far down and engaged. He did a speculum check, found I was over 10cm dilated, and then everything happened very quickly. The doctor demanded that I should be taken to the labour ward immediately and a midwife should be found to attend to her. An anaesthetist was called and I was given an epidural. I was hooked up to the monitor and when I sat up for the epidural they could see that the baby’s heart rate was dipping into negative at every contraction, so they called the same doctor back in. He called another doctor who took a blood test from the baby’s head. We were upgraded to a ‘code 1’ The doctor said we had to get the baby out urgently, and attempted to use a ventouse twice in the operating theatre before an emergency caesarean was performed immediately, with the room full of people. My baby was finally born. The doctor was shocked when my baby was born that no-one had told him there was meconium in the womb.

The care I and my son received on the ward before we went home was positive and reassuring.

However, the experience we had from Thursday to Saturday was traumatising and frightening. We are not sure why nothing happened for so long, why I was left alone for so long with frequent contractions and in great pain. It felt like a constant battle to get any attention . We could see that the staff were stressed, and indeed constantly said how stretched they were. There appeared to be only two midwives for 20 women – surely this cannot be right or safe? We don’t understand why I was admitted to Queen Elizabeth hospital when they were too busy to look after me.

Finally, we can see that the notes we were given which record the timing of stages and total length of labour bear no resemblance to what we experienced. Further the address in our records and the postcode were also wrong. We wonder why the notes are so inaccurate.

We were shocked by what happened to us,

We look forward to hearing from you.

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Responses

Response from Molly Baack, Associate Director of Communications, South London Healthcare NHS Trust

We are very sorry for the experience you had at the Trust at what ought to have been a happy time for you. This was unfortunately an exceptionally busy time for us at both our units (and across the area, with as you experienced Lewisham Hospital also very busy). We have systems in place that should ensure that even at these very busy times, women are still cared for properly in all our units.

On the rare occasion that one of the maternity unit (PRUH or QEW) cannot accept a woman in labour who is booked there, they will liaise with their sister site to ensure that a bed is available. On this occasion, both maternity units were extremely busy, which put pressure of the Delivery Suites on both the PRUH and QEW sites. An escalation plan exists within South London Healthcare to ensure safe staffing levels. On this occasion even with the additional four midwives on-call the activity within the maternity unit put pressure on staffing.

There were obviously a number of issues with your care, and I understand that one of our senior midwives has met with you to apologise for the distress caused and to discuss what happened. As a result of this, we have investigated the incident and we are reviewing our policies and talking to the midwives involved in your care. We are working hard to ensure that this incident will not be repeated, and that the concerns you have raised will help us ensure a better service for all women we see here.

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