Decision Report 201708632

Summary

Mr C's child (Child A) was born with several rare conditions that threaten life, affect physical and mental development and require extensive clinical and day- to-day management. Mr C complained that the board unreasonably failed to identify any indication of developmental conditions from scans of Child A during his partner's pregnancy. The board said that Child A's conditions were not identified earlier because they were either not detectable by ultrasound at any stage of pregnancy, were not part of the routine checks undertaken or appeared to be within normal limits for the relevant stage of pregnancy. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from an obstetric and sonography adviser (a specialist in the use of ultrasound in pregnancy). We found that Child A's kidneys did not appear normal in the 20 week scan and that immediate referral to a specialist would have been reasonable practice in those circumstances. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Acknowledge that they unreasonably considered Child A's kidneys appeared normal on the 20 week scan, and apologise to Mr C for this. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• A risk management multidisciplinary review should be undertaken about the board having missed the abnormality in Child A's kidneys.