A health board has apologised to a pregnant woman for failing to give her steroids.
The unnamed woman was admitted to Aberdeen Maternity Hospital with symptoms of pre-eclampsia.
Doctors decided to induce labour and it was thought she would need a caesarean.
She ultimately did not but, as part of the treatment policy for caesarean sections, she should have had steroids administered.
She complained to the Scottish Public Services Ombudsman (SPSO) watchdog, which has published a report recommending NHS Grampian apologise to her for not sticking to its own policy.
The report said: “The woman’s notes indicated there was a plan made that day for her to have a caesarean section and the board’s local policy on pre-term labour and birth indicated steroids should have been administered as a result.
“We considered that, in line with the local policy, the woman should have received steroids.”
SPSO said NHS Grampian should “apologise to the woman for failing to administer steroids in line with its local policy”.
It added that the woman’s blood should have been urgently tested, but concluded a delay in the test was unlikely to have had any bearing on the woman’s care and treatment.
An NHS Grampian spokesman said: “We have accepted the SPSO’s decision and recommendations in this case.
“The care we provided was not what it should have been.
“We have apologised to the patient involved and would also take this opportunity to apologise to them publicly.”
The woman also complained that, because she was given morphine, her baby experienced breathing difficulties.
She was also concerned her baby’s development would be affected because of the decision to give morphine.
However, the SPSO said it took independent advice from a consultant obstetrician and gynaecologist and concluded it was reasonable to provide opiate pain relief.
“We found the guidance indicates that, while morphine administration may have significant side effects for mother and baby, these side effects are considered to be short-term,” it said.
The woman also complained that doctors did not choose a caesarean delivery.
But the SPSO report did not uphold that aspect of her complaint, and noted that her labour “progressed very quickly”.