Decision Report 201701234

Summary

Mrs C complained that the board failed to take appropriate steps for her child's (Child A) plagiocephaly (asymmetry of the skull). Mrs C received several visits at home from the health visitor team following the birth of Child A and raised concerns about the shape of Child A's head when they were three months old. Mrs C later attended her GP and was referred to a paediatrician (a doctor who deals with the medical care of infants, children and young people) who diagnosed them with plagiocephaly. Mrs C considered that if the health visitors had identified problems with head shape sooner, it could have been prevented.

We took independent advice from a health visitor. We found that when the health visitor who visited Mrs C was advised of her concerns, they gave appropriate advice regarding positional changes to maintain Child A's natural head shape. However, no record was taken of the circumference of Child A's head or the shape. Therefore, there was no baseline information and we considered that it would have been reasonable to document this for later comparison. We also noted that there was no recorded plan to review the situation. We found that Mrs C was visited by several members of the same staff team but her concerns had not been shared between staff. It would have been appropriate to share this information to ensure continuity of care. We considered that if these steps had been put in place then Child A may have obtained physiotherapy support sooner. Therefore, we upheld Mrs C complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to follow up on her concerns about Chid A's head shape. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• All members of health visiting teams should have up-to-date guidance on the identification, assessment and management of plagiocephaly in young children.
• There should be a structured approach to care planning so that concerns and plans to review those concerns are documented.
• There should be effective communication within teams where several members of the team are providing care for the same family.
• There should be a review of their compliance with the Universal Health Visiting Pathway and a timeline provided for this review.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.