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Care and documentation relating to a woman with symptoms of pre-eclampsia (09HDC01311)

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(09HDC01311, 7 December 2010)

Independent midwife ~ Pre-eclampsia symptoms ~ Urinalysis ~ HELLP Syndrome ~ Emergency Caesarean ~ Documentation ~ Rights 4(1), 4(2)

A 30-year-old woman became unwell with vomiting 37 weeks into her first pregnancy. She made contact with her independent LMC midwife at least twice in two days regarding her symptoms. During this period, two other clients of the midwife went into labour. The midwife considered that the woman had a gastric bug and did not visit her. The LMC did not routinely perform urinalysis.

The woman's symptoms persisted through to the next day, when she visited a GP who considered that she had signs of pre-eclampsia and sent her for urgent blood tests, which indicated this diagnosis. The LMC was advised of the results, but decided that her client could wait until she could see her at the hospital the following morning at a previously scheduled appointment. The following morning, the woman had further tests and saw a specialist at the hospital. Her condition had worsened overnight and severe pre-eclampsia was diagnosed. The woman's baby had to be quickly delivered prematurely by emergency Caesarean section under a general anaesthetic.

This case was characterised by marked deficiencies and omissions in the midwife's record-keeping. The midwife failed to recognise, and react in an appropriate fashion to, her client's ongoing symptoms. The midwifery care provided was substandard and she was found in breach of Right 4(1). She also breached Right 4(2) as her documentation did not comply with professional standards.