Baby’s death from heart defect was avoidable (August 2019)

Summary

The Parliamentary and Health Service Ombudsman (PHSO) were set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. They share findings from casework to help Parliament scrutinise public service providers. They also share their findings more widely to help drive improvements in public services and complaint handling.

Miss K complained to the PSHO about the care and treatment that her son, Baby K, received at the Trust in November 2015. She said that the Trust failed to act following various checks on Baby K, and it failed to escalate his care in line with the seriousness of his condition and he died as a result. Miss K also complained about the Trust’s handling of her complaint.

Content

The PSHO found that the Trust failed to:

• act on the results of the ECG and chest X-ray
• consider Baby K’s history and symptoms
• ask for input from specialist staff
• escalate his care when his condition was getting worse.

If these failings had not occurred, it is likely that the Trust would have recognised that Baby K had a problem with his heart. In these circumstances he would have received the correct treatment instead of being treated for suspected pneumonia. The PSHO found that on the balance of probabilities, his cardiac arrest would not have occurred and it is more likely than not that his death would have been avoided.

The PHSO also found that the Trust was not open and accountable in its handling of Miss K’s complaint, as it failed to acknowledge and apologise for its mistakes in a timely manner. It also failed to signpost Miss K to the PSHO at the right time and in the right way.