PI Brief Update

Short notes on the Obstetrics and Gynaecology Service - Dr Mark Burgin

10/03/26. Dr Mark Burgin returns to his occasional series on clinical negligence cases and discusses how lawyers can approach problems in Obstetrics and Gynaecology.

The high numbers of maternity services that are given low scores by the CQC indicates that the problems are more often systemic than individual. Obstetrics and Gynaecology Service managers and leaders have failed to turnaround the problem. From Morecambe Bay (2015), East Kent (2022), Shrewsbury and Telford review (Ockenden) and the ongoing National Maternity and Neonatal Investigation (Baroness Amos, 2026) the same problems and solutions have been proposed.

These investigations have found that problems go beyond the NHS wide issues of dysfunctional relationships, falsifying medical records, tribalism seeing mothers and other staff as difficult (professional gaslighting). They list the problems as seeing caesarean delivery as a failure, failure to provide basic care (fluids, checks and hygiene), poor triage, poor response to high risk, failure to review deaths. Often

The inquiries have prescribed training (communication, cultural), staffing, leadership (safety champions), independent investigations (MNSI) to ‘overcome deeply ingrained cultural and systemic issues’. They say that the regulators need to consider mothers experiences, staff ratios / qualifications and outcome figures (stillbirth neonatal death, emergency transfers and brain injury) as well as the normal tick box checks.

Lawyers encounter claimants who can provide a detailed description of a clearly unpleasant experience. These claimants appear more highly educated and traumatised by the experiences than from other clinical negligence. When investigating the case the lawyer may find it difficult to identify a single breach or loss. Often they get the impression of a dysfunctional department and a catalogue of errors.

Despite being involved in many Obs and Gynae clinical negligence cases and hearing hundreds of personal stories I have struggled to write this article. Unlike other areas where the system is effective but there are mistakes Obs and Gynae problems are due to system breakdown. To understand what goes wrong we must consider where things go wrong in Obs and Gynae as the same doctors provide both services and problems in one area will impact others.

General practitioner care

GPs are essential to obstetric care as they monitor blood pressure, nutrients, immunisation and risks with foetal growth monitoring but their industrial action is causing reduced efficiency.

Patients are presenting later and with more severe complications from poor monitoring leading to increased need to intervene with admission and blood transfusion.

There appears to be issues with the quality of monitoring by the obstetric team for instance not addressing GP problems at clinic and lack of virtual follow up for important issues.

There needs to be increased monitoring by midwives and obstetricians and focus on the areas that GPs would normally provide.

The solutions are moving staff from other tasks, IT systems to provide an overview and new systems such as sending hospital prescriptions to pharmacies or allowing pharmacies to dispense them under Patient Group Directions.

Long term the GPs will respond to recognition of their role in obstetrics, support in ensuring proper funding by costing the adjustments and demonstrating the cost-offset of reduced emergency admissions.

Accident and Emergency

Triage assessment of Obs and Gynae patients in AE is currently of low efficiency leading to delays in diagnosis, starting treatment and referral to the on-call team.

Communication problems include the lack of an online system so the on-call team can check if any Obs and Gynae patients are in A and E, limited information at handover and delays in asking for assistance.

The problems appear to be overloaded A and E with excessive workload, lack of space for patients, no properly equipped Obs and Gynae examination room, failure to perform a pregnancy test and slow throughput.

The on-call team are not able to offer the best service to the A and E due to their need to cover multiple departments and manage priorities.

The solution is to have an electronic flag for all possible Obs and Gynae in A and E so that there can be shared responsibility for these patients.

The A and E professionals would be responsible for monitoring, investigating and treating the patients whilst in the department and the Obs and Gynae for assessing, advising and transferring unstable patients urgently.

Chronic pelvic pain

Chronic pelvic pain is a highly complex clinical problem which requires a multidisciplinary approach recognising that not all patients can be cured.

Currently these patients represent a large proportion of the attendance at outpatient, inpatient and emergency services and the best treatment may be self-management.

Often this disorganised engagement with the services means that the protocol is not followed, they have unnecessary CTs and they are given antibiotics.

However delayed laparoscopy and diagnosis can lead to closing of the window of opportunity and missed chance to prevent chronic disease.

The solution appears to be to move away from a medical model where the gynae team rule out gynae disease to a model where an MDT works through a protocol to find the diagnosis.

The full differential diagnosis should be considered in every patient and involvement of physio, STD, GI, MSK, psychological (trauma focused), neurological, drug side effects and so on.

One option is to have a special chronic pelvic pain clinic with additional funding for the team until the patient attendances fall significantly with better organisation and self-management.

Reasonable Adjustments for Disability

Staff in any area of medicine have functional restrictions which impact on their ability to perform the roles assigned.

Obs and Gynae involves surgery which requires an optimised physical condition for instance can be compromised by fatigue, hunger or thirst.

Pregnancy in Obs and Gynae staff can impact on the safe use of radiation in theatre and standing for long periods without a rest.

Where the operation requires higher levels of fitness and speed for instance emergency caesarean section each member of staff should be risk assessed.

A member of staff with physical functional limitations may require assistance to perform the simpler aspects of the operation so they do not become over tired.

A neurodifferent member of staff may require structured communication protocols (e.g., closed-loop communication) to thrive in high-stress environments.

Obs and Gynae can involve cognitive challenges and all staff should be given thinking time with complex cases as this may save time later.

Respect for the way that each staff member works and focusing on how the team works together is more important than having target numbers of patients seen.

Early pregnancy service

Early pregnancy services are likely to make the biggest impression on service users of the Obs and Gynae department.

The combination of unrealistic expectations, psychological distress, lack of effective treatment, bad news and first contact can make early pregnancy loss challenging.

The service can easily be overwhelmed as the numbers of miscarriages are high, they often present out of hours and the management of the associated psychological distress takes time.

Ultrasound machines and training are often a bottleneck so that waiting room is full of patients who are anxious and need monitoring.

The decision to offer evacuation of retained products of conception rather than expectant management or monitoring is complex particularly if the pregnancy is of unknown location.

Communication can be inconsistent and there are confidentially issues surrounding written information meaning that online advice may be a better approach.

A stepwise plan is essential so that the patient and their relatives feel that there is a process that will deal with all their worries and concerns.

This plan can also be useful to the staff when trying to explain the next step and the options available so that the staff can see that they have done everything they can.

Early pregnancy services have a role to provide support, bereavement and signposting but not counselling for other co-existing mental health issues.

The solution is to ensure that additional resources is available for the Early pregnancy services as required and psychological support for the staff delivering the care.

Time and motion

Surgical teams vary considerably in terms of their efficiency and safety with long gaps being common and poor compliance with safety standards.

A key problem is that individual members in a surgical team can work at different speeds so the team gets out of synch.

It is possible to make adjustments so that a slow member is assisted during time critical elements of the process or a fast member can do parallel processing.

If there are significant issues this means that the team has not been able to find a solution to their problems and they will require an investigation.

The most common problem is theatre turnaround (cleaning and anaesthetic) and change is often seen as impossible.

It is better to offer help so the team themselves request help with becoming more efficient than imposing an investigation as they need to be engaged with the process.

The investigation may indicate unmet needs from team members, bottle necks, low motivation or training or support needs.

The purpose of the investigation is to diagnose the problems rather than treat the problems and should be fed back to the team at a meeting.

It is then the responsibility of the team to ask for appropriate assistance to address their needs rather than impose treatments for the problems.

Conclusions

Inquiries do not appear to recognise that giving birth is emotionally and physically traumatic despite modern treatments. Maternity staff can help mothers manage their expectations and reduce but cannot abolish all trauma. Midwives and GPs roles have been downgraded and they have lost important skills. Problems such as burnout, poor supervision of juniors and transfer of work from in to out of hours are not limited to maternity but the costs of negligence are substantially higher.

There are many good Obs and Gynae departments but there are others that suffer from communication breakdown, problems with boundaries with other departments and workforce burnout. Managers appear to be both the cause for the problems and to have the solutions. Although leaders and regulators could do more to address the failing departments the key interventions are within the reach of hospital management.

They could perform risk and disability assessments, check skill levels and offer training and adjustments to job descriptions. They could arrange time and motion studies and offer feedback to the surgical teams. Additional resources could be requested to manage short term issues such as chaotic chronic pelvic pain and early pregnancy services and lack of ultrasound capacity. IT systems could be reviewed to ensure that timely communication is possible.

Lawyers can ask for disclosure of management decision making in the relevant area. Hospitals have understandably been reluctant to disclose evidence that could be used in multiple cases. Freedom of Information requests and involvement of politicians can help augment the lawyer’s options.

The experience of Obs and Gynae services is unacceptably poor compared to other healthcare and lawyers should explore how they can establish a breach of duty to provide psychological safety. Doctors should not harm their patients and should communicate in a way that shows comparison and respect to distressed patients. Additionally Obs and Gynae procedures have a significant potential to retraumatise patients.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 01226 761937 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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