Decision Report 201305990

Summary

Mrs C complained that staff at the Royal Hospital for Sick Children failed to provide her baby (Baby A) with a reasonable standard of clinical treatment. Baby A was born with hypoplastic left heart syndrome (a complex congenital heart condition) and needed surgery shortly after birth. Baby A became unwell and on the advice of her GP Mrs C took the baby to the hospital for assessment. Staff there considered whether intussusception (a condition in which one segment of intestine 'telescopes' in to an adjacent segment) might have been the problem but discounted this. They carried out additional investigations, including blood tests, but Baby A died shortly after this.

Mrs C said the blood tests were unnecessary and caused her baby distress. She felt that if medical staff had recognised the problems sooner and started treatment earlier, then the outcome might have been different.

We took independent advice from one of our medical advisers, who is a consultant paediatrician. The adviser explained that Baby A was born with a complex and very serious heart condition. Despite the surgery received following birth, this heart condition meant that Baby A was particularly susceptible to sudden and unexpected death.

The adviser said that a diagnosis of intussusception was immediately suspected when Mrs C took Baby A to hospital, but a cause is not always found for the condition. Our adviser also could see no evidence that a delay in a registrar reviewing Baby A had any impact on the final outcome. There was no evidence that Baby A suffered from a treatable or correctable problem that was missed or that treatment was delayed because of the delay in the availability of a registrar. There was also no evidence that a blood sample should have been taken earlier or that earlier involvement of the cardiology (heart) team would have made a difference. While the adviser considered that Baby A's oxygen saturation level should have been constantly monitored, it was impossible to say whether this would have made a difference. In light of the evidence, we found that, on the whole, the actions of the medical staff who treated Baby A were reasonable.

Recommendations

We recommended that the board:

• share with the relevant staff our adviser's comments in relation to the monitoring of Baby A's oxygen saturation and the early warning score now in use.