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Decision Report 201404521

  • Case ref:
    201404521
  • Date:
    January 2016
  • Body:
    Lothian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about the care and treatment she had received at the Royal Infirmary of Edinburgh after the birth of her son. We took independent advice from a midwifery adviser. We found that, in general, the care and treatment provided to Mrs C had been reasonable. However, on the night of her son's birth, Mrs C had been left in bed with a buzzer that was not working. Given that she was sedated and had had a spinal anaesthetic, we considered that this was unreasonable and upheld the complaint. The board had already apologised to Mrs C for this and had reminded staff to check that buzzers are working when patients are admitted, and so we did not make any recommendations.

Mrs C also complained about the care and treatment provided to her baby. We found it was unreasonable that he had been left unclothed all night, although this did not cause the subsequent deterioration in his condition. We also found it had been unreasonable that staff had taken the baby away during the night without documenting Mrs C's consent to this. Although we upheld this aspect of her complaint, we were satisfied with the action that the board had taken in response to Mrs C's complaint and did not make any recommendations.

Mrs C's baby had then been admitted to the neonatal unit (specialising in the care of newborn babies). Mrs C complained that they had carried out procedures on her son without her consent. We took independent advice on the treatment the baby received there from a medical adviser who is a consultant neonatologist. We found that staff in the unit should have taken steps to obtain verbal consent from Mrs C before carrying out a lumbar puncture (where tests are carried out by inserting a needle into the lower part of the spine). We also upheld this aspect of her complaint, although we noted that the board had already apologised to Mrs C for this.

Recommendations

We recommended that the board:

  • provide evidence that staff in the neonatal unit have been informed of our decision that they should have obtained verbal consent before carrying out the lumbar puncture.

Updated: March 13, 2018