Summary
Mr and Mrs C complained about the standard of care and treatment that Lothian NHS Board (the Board) provided to their child (Child A) in relation to their hearing from June 2012 until January 2018. Mr and Mrs C believed that Child A had a significant hearing impairment from two and a half to three years of age. They complained that this went undiagnosed, despite Child A undergoing multiple tests over a number of years with the Board’s Audiology Service. Mr and Mrs C said that the Board’s failure to diagnose Child A’s hearing impairment within a reasonable timescale affected Child A’s communication skills and, potentially, their ability to learn.
Mr and Mrs C explained that Child A had complex needs, including cerebral palsy and learning difficulties, and was also non-verbal. Child A failed the initial hearing screening test and was referred to the Board’s Audiology Service, who found that Child A may have some mild hearing loss in both ears. Child A was then seen by clinicians at the Board’s Audiology Service several times over the following years, and the audiologists told Mr and Mrs C that they frequently found it difficult to obtain reliable test results due to Child A’s communication difficulties. However, Child A was discharged from the Audiology Service twice as a result of staff being satisfied that they did not have any significant hearing loss.
Mr and Mrs C did not accept the test results, saying that the audiologists were not taking into account Child A’s symptoms and additional needs during testing. Following continued concerns being raised by Mr and Mrs C and Child A’s school, Child A was eventually referred to audiologists at another health board for a second opinion. A number of tests were carried out and Child A was diagnosed with severe to profound hearing loss in both ears. Child A was eight years old at that point. Child A was subsequently fitted with hearing aids which Mr and Mrs C observed appeared to have helped their hearing.
We took independent advice from a specialised audiologist. We found that there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process. We also found significant failings in the Board's investigation of Mr and Mrs C's complaint. The Board failed to identify even the most basic errors in the service they provided, as they should have done as part of their duty of candour, and the standard of their response to Mr and Mrs C was very poor.
We upheld Mr and Mrs C's complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr and Mrs C:
| Recommendation number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
1 |
We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process. We also found significant failings in the Board's investigation of Mr and Mrs C's complaint in that they failed to identify even the most basic errors in the service they provided as they should have done as part of their duty of candour and that the standard of their response to Mr and Mrs C was very poor |
Apologise to Mr and Mrs C for the failings identified in this investigation and inform Mr and Mrs C of what and how actions will be taken to prevent a reoccurrence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets |
A copy or record of the apology. By: 30 June 2021 |
We are asking the Board to improve the way they do things:
| Recommendation number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
2 |
We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process |
Review the failures in the diagnostic and testing process identified in this investigation to ascertain: how and why the failures occurred; any training needs; and what actions will be taken to prevent a future reoccurrence |
Evidence that the diagnostic and testing failings have been reviewed and learning taken from them to improve future service. By: 19 November 2021 |
|
3 |
We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process |
Arrange for an external audit of the testing of patients from 2009 until 2018 to be carried out to ensure there is no systemic or individual issue which may have affected other patients, and inform this office of the results |
Evidence of the audit and its results. By: 19 November 2021 |
|
4 |
We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process |
Feedback the findings of our investigation in relation to the failures in the diagnostic and testing process to relevant staff for them to reflect on |
Evidence the findings of our investigation have been fed back to relevant staff in a supportive manner. By: 30 June 2021 |
We are asking the Board to improve their complaints handling:
| Recommendation number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
5 |
We also found significant failings in the Board's investigation of Mr and Mrs C's complaint in that they failed to identify even the most basic errors in the service they provided as they should have done as part of their duty of candour and that the standard of their response to Mr and Mrs C was very poor |
Review the complaint handling failures to ascertain: how and why the failures occurred; any training needs; and what actions will be taken (or since then have been taken) to prevent a future reoccurrence |
Evidence that the complaint handling failings have been reviewed and action taken to prevent a future reoccurrence. By: 30 June 2021 |
|
6 |
We also found significant failings in the Board's investigation of Mr and Mrs C's complaint in that they failed to identify even the most basic errors in the service they provided as they should have done as part of their duty of candour and that the standard of their response to Mr and Mrs C was very poor |
Ensure Board investigations identify and address incidents covered by the duty of candour with the relevant Scottish Government guidance |
Evidence that the failure to comply with the duty of candour has been reviewed and action taken to stop a future reoccurrence. By: 30 June 2021 |