Decision Report 201508495

Summary

Ms C, who works for an advocacy and support service, complained on behalf of Ms A about a health visitor's monitoring of her infant daughter (Miss A). Miss A was diagnosed with hydrocephalus (an abnormal build-up of fluid in the brain) at around four months old. Ms C complained that this should have been picked up sooner.

We took independent medical advice from a health visitor, who considered that there were failures to appropriately record and interpret Miss A's head circumference, resulting in missed opportunities to identify the steep growth rate and make an appropriate referral for further investigation. In particular, it was noted that the measurement at Miss A's six to eight week assessment had crossed over the top centile and, in line with the board's policy, should have prompted referral. We concluded that the health visitor did not take appropriate action to monitor Miss A's development and we upheld the complaint.

Recommendations

We recommended that the board:

• provide training to relevant staff on the guidance in place for monitoring, recording and analysing growth measurements;
• take steps to ensure that health visitors receive adequate clinical supervision and are able to access support in cases such as this; and
• apologise to Ms A for the identified failure to appropriately monitor Miss A's development.