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Decision Report 201809062

  • Case ref:
    201809062
  • Date:
    July 2020
  • Body:
    Highland NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained on behalf of her child (Child A) that the care and treatment Child A received from the board was unreasonable. Ms C complained that there was an unreasonable delay in diagnosing Child A's hip dysplasia (when the hip socket doesn't fully cover the ball portion of the upper thighbone) and dislocated hip.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that it was unreasonable that Child A's legs and hips were not examined during a consultation. We considered that had Child A's hips and legs been examined and concerns noted, this should have prompted further investigations to be arranged, such as x-rays, and there was a high likelihood of an x-ray at this time indicating hip dysplasia. Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained that the board's handling of her complaint was unreasonable. We found that there were delays in the board's response to Ms C's complaint and the board did not provide proactive updates about the status of Ms C's complaint. We found that the board's handling of the complaint was not in line with the NHS Model Complaints Handling Procedure (MCHP) and, therefore, upheld this aspect of Ms C's complaint.

We noted that the board had already taken action to improve their complaints handling. We made no further recommendations but did provide feedback on this point.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C for the failings identified in the care and treatment provided to Child A and for the failures identified in the board's complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • Patients should be fully examined when presenting at an orthopaedic clinic and further investigations organised as appropriate.

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.

Updated: July 22, 2020