NHS Highland ordered to apologise after baby suffered brain damage
Register for free to read more of the latest local news. It's easy and will only take a moment.
NHS Highland has been ordered to apologise after a newborn child suffered brain damage while under the health board's care.
The child suffered a softening of brain tissue due to a series of failings during the mother's pregnancy and in the wake of the child's birth.
The Scottish Public Services Ombudsman (SPSO) ruled that medical staff had “failed to provide reasonable care to A [the woman] and their unborn child and that the board failed to fulfil their obligations under duty of candour”.
The parents, whose identity was not revealed, had to make a three-hour journey to a regional hospital in their own vehicle when the woman's waters broke.
After the baby was born it had to be resuscitated and suffered a softening of the white brain tissue known as periventricular leukomalacia.
The condition often causes issues later in life with muscle control and thinking or learning problems.
The ombudsman has ordered that the parents, who were not named in the report, are apologised to and a raft of measures are implemented to avoid repeats of such incidents.
NHS Highland has been told to establish record-keeping systems that prompt midwives to detail a full assessment and ensure there is cross-checking with the consultant unit at the regional hospital.
There is also a requirement to set up a protocol for managing premature rupture of membranes in remote locations and commence treatment where appropriate, prior to transfer.
Finally there should be a set of standard documentation and standard operating procedures for risk-assessing pregnant women in remote locations, to determine the most appropriate mode of transfer to the obstetric units.
A statement from the ombudsman said: “A and C [the other parent] both agreed to a caesarean. The procedure was carried out and the baby [B] was delivered. However, clinicians had to resuscitate B [the child].
"A scan of B’s brain three days after birth revealed a likely injury which was later confirmed as periventricular leukomalacia.
"Following repeated scans over several weeks as the cysts continued to form, this was eventually categorised as grade three level of severity. C raised concerns with the board regarding the care and treatment that A and B had received.
"C met various clinicians but remained dissatisfied. The board offered to have the events subjected to an external review but terms could not be agreed and the review was not carried out.
"We took independent advice from a neonatal consultant.
"We found that, during both admissions, the board failed to provide reasonable care to A and their unborn child and that the board failed to fulfil their obligations under duty of candour. We upheld the complaints.”
A spokesman for NHS Highland said: "We have fully accepted the recommendations in the report from the SPSO and actions are being implemented.
"Pam Dudek, our chief executive, has written to the family to apologise."
Campaign group Caithness Health Action Team described the chain of events at the centre of the SPSO ruling as something many families in the far north would recognise.
The group's chairman, Ron Gunn, also said the situation appeared to be at odds with the aims of Best Start, the Scottish Government's plan for maternity and neonatal services.
"Our thoughts are with the family," Mr Gunn said. “It must have been a very stressful experience to have to go through when the waters broke and they ended up going in their private car for three hours – something which a lot of Caithness families would recognise.
"It doesn't really fit in with the Scottish Government's Best Start. The idea of the Best Start is that your whole pregnancy is supposed to be a good experience for the mother, the child and the family.
"The fact that they had to go that distance under those circumstances certainly doesn't fit in with the Best Start.
"The record-keeping system for the midwives handing over to the consultant, that's something that we have highlighted before.
“Cross-checking with the consultant, again that is something that has been highlighted to us by other mothers."
On the requirement to set up a protocol for managing premature rupture of membranes in remote locations and commence treatment where appropriate, prior to transfer, Mr Gunn said: “That's something that might well apply to Caithness mothers.
"Not all of them actually go into the midwife unit in Wick – they're told to get in the car and get down to Inverness."
Mr Gunn also noted the comment that there should be a set of standard documentation and standard operating procedures for risk-assessing pregnant women in remote locations.
"That's something we've been shouting about for years," he said. "The risk assessment is not appropriate for the distance that these expectant mothers have to cover,
“There should be full, complete risk assessments, taking everything into consideration."
