Decision Report 201702665

Summary

Ms C attended an antenatal screening which tested for Down's syndrome before the birth of her child (Child A) and it was determined that she was at low risk to have a child with this condition. Following the birth, Child A was diagnosed with Down's syndrome. Ms C said that the board's communication with her about Down's syndrome, before and after the birth was unreasonable.

During the pregnancy, an ultrasound scan confirmed Child A had a hole in their heart. Child A died a few months after birth and Ms C complained that the board had unreasonably failed to diagnose, discuss and treat Child A's heart condition and breathing problems.

We took independent advice from a midwife and consultants in cardiology, emergency medicine and neonatology. We found that, before the birth of Child A, Ms C was given reasonable information about the Down's symdrome screening process but after their diagnosis there was little evidence of what had been said and discussed. There was no record of the conversation telling Ms C about Child A's diagnosis and the immediate plan for them. We upheld this aspect of Ms C's complaint.

In relation to Child A's heart condition and breathing problems, we confirmed that there are limitations in the antenatal screening process, with screening identifying only half the number of heart defects. We found that Child A's heart and breathing problems had been reasonably diagnosed and treated but that there were also lung problems which could have not been predicted. We did not uphold this aspect of Ms C's complaint.

Recommendations

What we said should change to put things right in future:

• Full records require to be maintained and available for a clinical audit trail and scrutiny.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.