Overview
The complainants (Mr and Mrs C) raised a number of concerns about the care and treatment provided to their baby daughter (Baby C) and Forth Valley NHS Board (the Board)'s failure to diagnose meningitis and hydrocephalus when she was seen by clinicians at Stirling Royal Infirmary (Hospital 1) on
20 September 2007.
Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide reasonable care and treatment to Baby C on 20 September 2007 (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mr and Mrs C for the failings identified in this report;
(ii) carry out a root cause analysis of the inadequate assessment on
20 September 2007. This should explore why the obvious concerns of the GP were not addressed by the junior paediatricians. It should also establish whether the staff grade doctor involved in the decisions was sufficiently trained and experienced to be in this position of responsibility. The Board should then give consideration to further training for the relevant staff in light of the results of their analysis of the case. They should also provide Mr and Mrs C with a full and detailed explanation of their findings and the steps that will be taken to prevent recurrence; and
(iii) note the specialist medical adviser's comments that a cranial ultrasound scan should have been performed on 20 September 2007 to exclude a build up of fluid in the brain.
The Board have accepted the recommendations and will act on them accordingly.