The parents of baby B, a newborn child delivered within NHS Highand’s catchment area, complained to Government watchdogs after healthcare professionals failed to provide “reasonable care” for the then-pregnant mum and unborn baby.
The mother of baby B, only referred to as ‘A’ in official documents, attended a local Highland hospital, experiencing abdominal discomfort during her pregnancy, before being sent three hours away to one of NHS Highland’s larger regional hospitals.
A and her partner, who is referred to as C, were then told labour may be starting, before healthcare professionals changed their mind and discharged the pregnant mum.
The following week, A suffered vaginal leakage and attended the local hospital where they were examined by a clinician and advised they suspected A’s waters had broken.
A was advised to again go to the main regional hospital and told an ambulance was not needed, so her partner drove her another three hours to the main regional hospital.
An examination at the main regional hospital revealed that A’s waters had broken and in the early hours of the following day she went into labour.
Later that afternoon, clinicians gave the couple a number of options: continue with natural labour, attempt a process of augmentation (helping along a labour that's not progressing as it should), or an immediate caesarean delivery. A and C both agreed to a caesarean. The procedure was carried out and baby B was delivered. However, clinicians had to resuscitate baby B.
A scan of baby B’s brain three days after birth revealed a likely injury that was later confirmed as periventricular leukomalacia – a softening of white brain tissue near the ventricles that often causes problems later with muscle control and thinking or learning problems.
The couple complained to the Scottish Public Services Ombudsman (SPSO) over the care they received. The watchdog has since investigated the care that A received from NHS Highland.
A spokesperson for the SPSO said: “We took independent advice from a neonatal consultant.
“We found that, during both admissions, the board failed to provide reasonable care to A and their unborn child and that the board failed to fulfil their obligations under duty of candour. We upheld the complaints.”
The SPSO has now ordered NHS Highland bosses to apologise “for failing to provide optimal care, for failing to carry out adequate assessment, for failing to complete suitable documentation and for failing to make safe transport arrangements”.
The health board must also “apologise to C and A for failing to provide reasonable care by omitting to timeously administer prophylactic antibiotics to A on arrival at the regional hospital and apologise for the board failing to fulfil their duty of candour obligations when the antibiotic incident was identified”.
Finally, “the board should offer C a final opportunity to address their outstanding questions in relation to the care of A and B in a format agreeable to both parties”.
A spokesperson for NHS Highland said: “We have fully accepted the recommendations in the report from the SPSO and actions are being implemented.
“Pam Dudek, our chief executive, has written to the family to apologise.”