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Decision Report 201902182

  • Case ref:
    201902182
  • Date:
    November 2020
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

C complained on behalf of their child (A), who was admitted to the Royal Hospital for Children with multiple bruises. Medical staff initiated child protection procedures to investigate if A's bruising had been caused by physical abuse. C raised various concerns about A's care and treatment. In particular, that the decision to initiate child protections was disproportionate; that unnecessary and distressing medical investigations were carried out on A; and there was a lack of communication with C.

We took independent advice from a consultant paediatrician. We found that it was reasonable child protection procedures were initiated and that no unnecessary medical investigations were carried out. However, we found that there was a failure to communicate clearly with C about what was happening at the outset so we upheld their complaint.

C also raised concerns about how the child protection process was concluded. We found that there was an unreasonable delay in the board concluding their part of the child protection process. We also found that the outcome should have been recorded in A's medical records. We upheld their complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified in the communication with them and in relation to how the child protection process was concluded. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
  • As it could be relevant to future care and treatment, A's medical record should contain information about the final outcome of the child protection process.

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

  • Families should be given prompt and clear information about the child protection process. It should then be documented in sufficient detail.
  • When child protection concerns have been raised, medical reports should be provided within a reasonable timeframe, taking into account relevant clinical guidance.
  • When child protection concerns have been raised, the child's x-rays should be reported in a timely manner, taking into account relevant clinical guidance.
  • When child protection procedures are initiated in hospital, the child's medical record should contain information about the final outcome so it is available to hospital based medical staff if the child is readmitted.

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: November 18, 2020