Decision Report 201401047

Summary

Mr C complained that clinical staff at The Royal Hospital for Sick Children (Yorkhill Hospital) had not diagnosed his newly born son's illness. Mr C said he took his son to the hospital three times (he left the second time without being seen due to concerns about cleanliness), but it was only on a family holiday some weeks later in England that his son's pyloric stenosis (tightness of the muscle that connects the stomach to the small bowel, thus causing problems with digesting food and vomiting) was identified.

We considered whether the evidence indicated that clinical staff had acted reasonably. We took independent advice from our medical adviser, who confirmed that pyloric stenosis evolves over time. He said there was no specific guidance that staff should have followed in such a case and, on the basis of the information available at the time, he said it was not unreasonable that staff did not carry out additional investigations for pyloric stenosis. Although we took Mr C's concerns into account, we did not consider that the evidence indicated that the care was unreasonable. We did not uphold this complaint, but we did make one recommendation because a urine test had been misinterpreted by a junior doctor as pointing to an infection.

In terms of Mr C's complaint about the cleanliness of the hospital on his second visit (when he left before being seen), the evidence was limited to the signed cleaning checklists for that day and Mr C's version of events. Although we did not in any way doubt his honesty, and we recognised that the cleaning logs did not absolutely prove the level of cleanliness at any one time, on the basis of the limited paperwork available, we did not uphold this complaint.

Recommendations

We recommended that the board:

• consider reviewing their staff guidance for interpreting urine culture results.