Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    February 2015
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Not upheld, no recommendations


Ms C complained to us on behalf of her relative (Ms A) in relation to the care and treatment of Ms A's late baby (Baby A). Baby A was born at University Hospital Crosshouse following a normal delivery, and was assessed at birth to be fit and well. Around three hours after birth, the baby's temperature was taken using an adult thermometer, as no paediatric thermometer could be found. As the temperature was found to be low, Baby A was placed under an overhead heater, and was monitored carefully. After half an hour a paediatric thermometer was used to take Baby A's temperature, which had returned to normal levels. A paediatrician reviewed Baby A an hour later, and assessed Baby A as fit for transfer to the maternity ward. Following another 20 hours of monitoring, mother and baby were assessed as fit for discharge.

Two weeks later, Baby A took severely ill and was taken to A&E. Baby A was treated by a team from the intensive care team from the nearest children's hospital, and was immediately transferred there. Baby A died four days later, from late onset Group B streptococcal septicaemia (a bacterial infection of the blood), which developed into meningitis (an infection of the lining of the brain).

Our adviser found that the monitoring of Baby A's temperature in the first 24 hours of life was appropriate. He also noted that, while one temperature reading was not taken appropriately, this was rectified soon after, and subsequent readings were appropriately timed and were taken with the right equipment. The adviser considered the standard of care to be good, and did not raise any concerns about the management of Baby A's temperature. He also clarified that concerns about Baby A's temperature in the first day of life did not have any impact on the subsequent infection. On the basis of this advice, and as the board met with the requirements of the guidance on the management of infection in new-born babies, we did not uphold this complaint.

Download case 201302667 as a PDF (11.54 KB)

Updated: February 18, 2015