Scottish Public Services Ombudsman

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  • Report number:
    201507831
  • Date:
    December 2016
  • Body:
    Forth Valley NHS Board
  • Sector(s):
    Health
  • Keywords:
    Delay in diagnosis; clinical treatment

Summary
Mrs C's child (Child A) had been suffering from vomiting and headaches and was referred to a paediatrician at Forth Valley Royal Hospital in January 2014.  The paediatrician saw Child A on three occasions from January 2014 until July 2014.  In August 2014, Child A collapsed at home and was admitted to Forth Valley Royal Hospital as an emergency.  Child A was diagnosed with a brain tumour. They underwent lengthy and difficult surgery to remove the tumour, but it was impossible to remove it completely.  Mrs C said that despite the evidence of Child A's deteriorating condition, the paediatrician failed to record their symptoms and carry out appropriate tests, referrals and investigations.  Mrs C also said that the paediatrician failed unreasonably to consider a serious cause of Child A's symptoms.  As a result, Mrs C believed that Child A's brain tumour should have been detected much earlier and that they suffered unnecessarily.

During the investigation, my complaints reviewer took independent advice from a specialist in paediatrics and a specialist in paediatric neurosurgery.  The first adviser considered that Child A should have been referred for a brain scan in April 2014 (at the least) and that the paediatrician's failure to consider that Child A may have a brain tumour and arrange appropriate scans and referrals was below an acceptable standard of care.  I accept that advice.  I am particularly concerned about the paediatrician's failure to act in July 2014 given that they had documented their awareness of headaches in addition to ongoing vomiting.  The second adviser said that it was likely an earlier diagnosis would have meant a smaller tumour and a shorter, less challenging operation.  My view is that these failures led to a significant personal injustice to Child A.  The unreasonable delay meant that an opportunity to completely remove the tumour was missed, and in this respect I note that Child A required additional treatment (chemotherapy) with significant risks and was left with neurological defects.  In addition, Child A's collapse was very traumatic for them and their family.  Given the evidence and information available to the specialist about Child A's condition (from January 2014 onwards), I am extremely concerned about their failure to properly assess and investigate Child A's symptoms, and their failures raise questions about their competence.  In view of the failings identified, I upheld the complaint about the clinical care and treatment provided and made recommendations.  However, I did not make recommendations that relate directly to the paediatrician because they are no longer an employee of the health board.

Redress and recommendations
The Ombudsman recommends that the board:

  • ensure that all relevant healthcare professionals are aware of the guidelines relating to the diagnosis of brain tumours in children and young people (the HeadSmart programme); and
  • apologise to Mrs C for the failures identified.

Download report number 201507831 as a PDF (47.67 KB)

Updated: December 21, 2016