Decision Report 201905072

Summary

C complained about a failure to diagnose that their new born baby (A) had a dislocated hip from birth. A was reviewed by a physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) at the Royal Hospital for Sick Children, and C raised concerns that their request for an ultrasound scan was refused despite the presence of a number of red flag risk factors for hip dysplasia (where the 'ball and socket' of the hip are not properly formed). A's condition was not diagnosed until some months later.

The board noted that the physiotherapist found A's hips to be functioning normally. They accepted that initial screening will always have the opportunity for human error. They said that this is mitigated by regular teaching and peer review, and ensuring staff are competent in examination before reviewing patients. However, as a result of this complaint, they made changes to their hip screening procedures.

We took independent advice from a paediatric physiotherapy specialist. We considered that the presence of a number of recognised risk factors of hip dysplasia, together with a doctor's prior positive clinical assessment of hip instability, should have led the physiotherapist to arrange an ultrasound. The decision not to carry out a scan of A's hips was unreasonable and resulted in a delayed diagnosis. We upheld this complaint. We were advised that the changes already made by the board to their hip screening procedures should improve the clinical process going forward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to arrange an ultrasound scan, and the resulting delay in diagnosing A's condition. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• An audit process should be established to ensure that improvements in teaching and peer review are followed through and that staff continue to meet their competencies.
• The board should share this decision with the physiotherapist in a supportive manner, and ask that they reflect on A's case.

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.