Decision Report 201300937

Summary

After Ms C's son (Master A) was born, he had problems taking milk and keeping it down and it often flowed from his nose when feeding. He also had a blocked nose and colic and did not sleep well. He was late to start talking, his pronunciation was poor and his speech was quite nasal. He developed behavioural problems, stemming from his frustrations about his speech. In 2011, Master A was referred to an ear nose and throat (ENT) specialist and was diagnosed with a cleft palate. Ms C then complained that her son had displayed classic signs of this condition, but multiple health professionals had failed to make a diagnosis.

Master A had a submucous cleft palate (where the muscles of the soft palate were not joined as they should be). We took independent advice from one of our medical advisers about the complaint, and accepted their advice that this type of cleft palate is invisible and would not be identified through routine mouth examinations. The adviser said that this is normally diagnosed when the child starts to speak, and speech problems are identified. We found that Master A's symptoms were investigated appropriately when Ms C raised them and in November 2011 he was appropriately referred to an ENT specialist. Due to a misunderstanding, however, this appointment was missed and there was a seven-month delay before another appointment was secured and a diagnosis made. We were satisfied, however, that the board were not responsible for the delays and that staff could not have diagnosed and treated Master A's condition any sooner.