Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Cwm Taf Morgannwg University Health Board
Ms B complained about the Health Board’s handling and investigation of safeguarding concerns when her child, Baby A, presented to hospital with a head injury. She raised concerns about consent and information, the diagnostic investigations undertaken and the responses given to Social Services. Care proceedings were taken based on CT scan findings indicating possible non-accidental injury, but this was subsequently found to be unsubstantiated.
The Ombudsman found shortcomings in relation to obtaining informed consent (in line with GMC guidelines) for the investigations as there was insufficient evidence that adequate discussions took place with Ms B about the safeguarding process and how the results of investigations might be used. The Ombudsman also found that, given the nature and diagnostic uncertainty of the CT scan findings, and the young age of Baby A, a specialist paediatric neuroradiology review should have been obtained. Whilst this review was requested by Health Board staff, it was not provided as the Health Board’s arrangements were not sufficiently robust to ensure access to this when indicated. It was impossible to say whether a further opinion would have changed the subsequent events, but the failure to obtain such an opinion resulted in uncertainty about the completeness of the radiological review of the CT scan, which was an enduring injustice to Ms B and her family.
The Health Board accepted the Ombudsman’s recommendations. These included putting in place a formal mechanism for obtaining specialist paediatric neuroradiology review in cases where this was indicated, and review of its ‘consent to medical assessment’ form to support the taking of informed consent. It also agreed to make a redress payment of £1500 to Ms B.