Overview
The complainant (Ms C) raised concerns about the treatment that she received from Dumfries and Galloway NHS Board (the Board) prior to the birth of her son (Baby A). She also complained about the treatment Baby A received after he was born.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board failed to diagnose that Ms C had pre-eclampsia, despite her showing clear symptoms (not upheld);
- (b) the Paediatrician's arrival was excessively delayed, despite Ms C and her family's concerns over Baby A's breathing (upheld);
- (c) the Paediatrician failed to properly prioritise Baby A (upheld);
- (d) the Midwife failed to recognise that there were problems with Baby A feeding when she gave him formula milk (not upheld);
- (e) the Board failed to diagnose Persistent Pulmonary Hypertension of the Newborn despite Baby A showing clear symptoms (upheld);
- (f) the Doctor treating Baby A did not know how to increase the oxygen when this was requested by the Consultant (not upheld); and
- (g) Ms C was refused entry into neonatal when Baby A was admitted and she was not called when he received a heart massage (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) remind midwifery staff of the importance of maintaining consistent records of babies' physiological observations;
- (ii) present Baby A's case, and Adviser 2's comments, to Neonatal staff to highlight any learning points that can be taken from this case; and
- (iii) apologise to Ms C and Mr B for the issues highlighted in this report.
The Board have accepted the recommendations and will act on them accordingly.