Summary
Mrs C complained to us about the care and treatment provided to her late son, (Baby A), at the Aberdeen Royal Children's Hospital. Baby A had been fitted with a shunt (a medical device that relieves pressure on the brain by draining excess fluid into the abdominal cavity) shortly after he was born. Mrs C complained that when he was admitted to the hospital several months later, there were multiple failings in care and treatment. Baby A passed away in a specialist paediatric neurosurgery centre under another health board a few days after his admission to the hospital.
During our investigation, we took independent advice from a paediatrician, a neurosurgeon, and an anaesthetist. We found that although the board's internal investigation had identified some issues in Baby A's care and treatment, they had not addressed the important issues with the episode of care. Our investigation determined that there was a lack of clarity regarding the roles of each medical team, and that there was a lack of communication between consultants when Baby A's condition was not improving. We also found that the neurosurgical team had not kept reasonable records, nor had they appropriately assessed Baby A before and after operations. We identified significant delays in Baby A being reviewed after he underwent operations, and a delay in clinicians contacting the specialist centre for advice on the management of Baby A. Finally, we considered there to have been a lack of communication from the neurosurgical team and Baby A's parents. Given the multiple failings identified by our investigation, we upheld this aspect of Mrs C's complaint.
Mrs C further complained to us that after Baby A's death, the board did not contact her or communicate with her until she submitted her complaint. The board accepted that this was unacceptable, and we upheld this aspect of Mrs C's complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|
There were multiple failings in care and treatment provided to Baby A when he became unwell in August 2015; and the Board failed to reasonably communicate with Mrs and Mr C following Baby A's death |
Apologise to Mrs and Mr C for the failings in care and treatment provided to Baby A when he became unwell in August 2015; and for failing to reasonably communicate with Mrs and Mr C following Baby A's death |
Copy of apology letter By: 19 July 2017 |
We are asking the Board to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|
There was a lack of clarity regarding the roles of each team in the care and treatment of Baby A |
Roles of each team in situations of joint care (for example neurosurgical and paediatric) should be made clear |
Evidence of consideration by the Board as to how teams can clarify roles in situations of joint care By: 16 August 2017 |
|
There was no 'consultant to consultant' discussion when it became clear that Baby A's condition was not improving |
Consultants in situations of joint care should discuss a child's presentation when it becomes clear that their condition is not improving |
Evidence that this has been fed back to relevant staff (for example, a copy of the minutes of discussion of the complaint at a staff meeting or of internal memos/emails, or documentation showing feedback given about the complaint) By: 19 July 2017 |
|
The Board's internal investigation focussed on the shunt tap attempt as a reason for Baby A's continued deterioration, when in fact it is unlikely that this had any impact on Baby A's clinical status |
Internal investigations should involve the appropriate specialisms to identify what issues are pertinent to an episode of care |
Evidence that this has been fed back to relevant staff By: 19 July 2017 |
|
There was poor record-keeping by the neurosurgical team |
Records made by all clinicians should be in line with national guidance and note all relevant factors in decision making |
Evidence that this has been fed back to relevant staff By: 19 July 2017 |
|
There was a failure of the neurosurgical team to document any neurological assessment of Baby A pre- or post- operatively |
Neurological assessment should be fully carried out and recorded both before and after operations to revise a ventriculo-peritoneal shunt |
Evidence that this has been fed back to relevant staff and evidence that the Board have considered implementing guidelines with regards to neurological assessment pre- and post- ventriculo-peritoneal shunt revision By: 16 August 2017 |
|
There was a lack of post-operative review of Baby A by the neurosurgical team |
There should be clear plans in place to review children in a timely manner after neurosurgical procedures |
Copy of protocols put in place which note time stipulations for reviewing children after ventriculo-peritoneal shunt revision By: 13 September 2017 |
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Baby A's condition was not discussed with the specialist paediatric neurosurgery unit until after the second operation |
Clinicians should be clear when to discuss cases with specialist units, rather than it being left to the discretion of the individual clinician. |
Copy of more specific guidance on which children should be discussed with specialist units By: 13 September 2017 |
|
There was a lack of communication from the neurosurgical team with Mrs and Mr C |
Clinicians should be clearly communicating with parents of children in the high dependency unit |
Evidence that this has been fed back to relevant staff By: 19 July 2017 |
|
Until Mrs C made a complaint, Board staff did not communicate with Mrs and Mr C after the death of Baby A |
Relevant clinical and management staff should initiate communication with the family soon after a child dies |
Copy of protocol which stipulates arrangements for communication after a child dies By: 13 September 2017 |