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Decision Report 201803965

  • Case ref:
  • Date:
    June 2020
  • Body:
    Grampian NHS Board
  • Sector:
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Ms C complained about both the health visitor and hospital care provided to her child (Child A) in the context of child protection safeguarding. Ms C felt that there had been a lack of action taken by the health visitor when she reported Child A had ongoing diarrhoea and had a hard and bloated stomach. Ms C was also concerned that child protection procedures should not have been instigated and that the process was not properly communicated to her or reasonably followed in terms of the alleged facial markings on Child A.

In responding to the complaint, the board considered that the actions and care provided by staff were appropriate in terms of Ms C's complaints.

We took independent advice from a registered health visitor and from a consultant paediatrician.

In terms of the care provided by the health visitor, we considered that the care provided to Child A was appropriate and that it was correct to instigate child protection proceedings. However, we upheld this complaint on the basis that there was a failure to either reasonably communicate the decision about instigating child protection proceedings to Ms C or to record the decision not to communicate this to her.

We found that the care provided by the hospital was reasonable, therefore, we did not uphold this complaint on the basis that child protection procedures were appropriately followed.

However, we were critical of the board's original complaint response to Ms C as it provided limited detail of their complaints investigation in relation to the actions of the health visitor.


What we asked the organisation to do in this case:

  • Apologise to Ms C for not following the National Guidance for Child Protection in Scotland. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

  • Staff should document that they have either communicated the decision to instigate child protection procedures to the family or to record the decision not to do so, in line with the National Guidance for Child Protection in Scotland.

In relation to complaints handling, we recommended:

  • Complaint responses should address the issues raised, in line with the Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: June 17, 2020