NHS Highland ordered to apologise after newborn suffered brain damage
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A baby suffered a softening of brain tissue due to failings during the mother’s pregnancy and in the wake of the child’s birth.
The Scottish Public Services Ombudsman (SPSO) ruled 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 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 an apology and measures to avoid repeats of such incidents.
NHS Highland has been told to establish systems that prompt midwives to detail a full assessment and ensure there is cross-checking with the consultant unit at the regional hospital. A protocol must also be established to manage 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 operating procedures for risk-assessing in remote locations, to determine the most appropriate mode of transfer to the obstetric units.
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.
“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 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.”
A spokesman for NHS Highland said: “We have fully accepted the recommendations in the report from the SPSO and actions are being implemented.”
