NHS Grampian has been ordered to provide further training and supervision, after a health visitor failed to spot a baby had abnormal fluid on the brain.
Complaints lodged by the mother of the infant claiming the problem was not picked up early enough were upheld by the Scottish Public Services Ombudsman (SPSO). It found the condition – known as hydrocephalus – was not spotted because of “failures to appropriately record and interpret” the size of the baby’s head.
The watchdog found that measurement taken at four to six weeks should have raised alarm bells, however a diagnosis was not made until the age of four months.
A GP has already apologised to the mother for not personally checking the charts.
NHS Grampian has now been told by the ombudsman to provide further training on the guidelines and “adequate clinical supervision” for health visitors.
The SPSO decision report stated: “We took independent medical advice from a health visitor, who considered that there were failures to appropriately record and interpret Miss A’s head circumference, resulting in missed opportunities to identify the steep growth rate and make an appropriate referral for further investigation.
“It was noted that the measurement at Miss A’s six to eight week assessment had crossed over the top centile and, in line with the board’s policy, should have prompted referral.
“We concluded that the health visitor did not take appropriate action to monitor Miss A’s development and we upheld the complaint.”
The SPSO also found an “unreasonable failure” to properly plan the discharge of a hospital patient. The man, who was unable to make his own decisions, was discharged to a community hospital “against his family wishes and without relevant documentation”, it reported. He later died a day after being sent home. The watchdog said a “breakdown in communication” meant medical staff “wrongly informed other staff about the family’s wishes”.
A spokeswoman for the health board said: “We fully accept the ombudsman’s findings.”