The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust

5. Mrs P complains about the Trust’s treatment between when her son was born in March to 22 April 2022.

6. Mrs P has complained that the Trust failed to diagnose him with pyloric stenosis after it completed an ultrasound on 19 April. Mrs P is also concerned that the radiologist took incorrect measurements on the same ultrasound.

7. Mrs P complains the Trust’s actions led to O becoming very dehydrated and she believes he would have died if she had not taken him back to hospital on 20 April. Mrs P said this was traumatic for her and it has been very difficult for her to process the stress it caused.

8. Mrs P wants the Trust to make changes to prevent the same mistake happening again.

9. On 11 April O projectile vomited twice, once in the morning and once in the evening. The next day he vomited more often and became constipated. Mrs P took him to A&E on the advice of his GP. The doctors in A&E suggested he might have pyloric stenosis or reflux. Reflux is a condition where stomach acid moves up towards the throat. As staff thought reflux was the most likely cause of O’s symptoms, they took blood gases (a measurement of how much oxygen and carbon dioxide there is in the blood). The Trust prescribed omeprazole (a medication to reduce the amount of acid the stomach makes) and discharged him.

10. Between 13 and 15 April, O continued to projectile vomit despite the medication. On 16 April Mrs P took him back to A&E. The doctors weighed O and recorded he had lost 100g. They also retook his blood gasses and noted them as normal. The Trust discharged O from A&E and sent them home.

11. On 18 April O’s condition worsened so Mrs P returned to A&E with him. He had not had a wet nappy all day and when weighing him the doctors found he had lost more weight and was close to his birth weight. The doctor thought O’s condition could be a milk allergy, reflux or pyloric stenosis. The doctor took blood cultures and admitted him to the ward until they could diagnose the cause of his illness.

12. On 19 April a radiologist did an ultrasound to measure O’s pylorus muscle (the muscle between the stomach and the intestines). The radiologist who did this was not a paediatric specialist. The radiologist measured O’s pylorus muscle and the Trust decided this showed he did not have pyloric stenosis. The Trust discharged O on 20 April.

13. After being discharged, O projectile vomited after each feed. At 10pm he vomited a brown bubble and Mrs P phoned the Trust. A nurse advised Mrs P to take O back to the ward. Once on the ward, the Trust gave him intravenous fluids (fluids given directly into the veins).

14. On 21 April the Trust got a second opinion from a paediatric specialist at a different trust. The paediatric specialist completed a second ultrasound, which they said showed he had pyloric stenosis.

15. On 22 April the Trust transferred O to the other trust where he had surgery the next day to treat his pyloric stenosis.

20. We first considered if the Trust’s radiologist took the correct measurements when assessing O’s ultrasound on 19 April. The radiology examination report states that the pyloric length was 10mm and that the pyloric width was 10mm. But, we are not convinced these measurements are accurate. Our adviser explained the ultrasound shows the pyloric length was 17mm and the width was 12.6mm. They explained this shows O had an abnormal pylorus.

21. The GMC guidance states that in giving clinical care doctors must, ‘adequately assess a patient’s condition’. There is evidence that the Trust’s radiologist did not take the correct measurements. We think this was a failing because we cannot say the radiologist properly assessed O’s condition.

22. We then considered if, based on the available information, the Trust should have diagnosed O with pyloric stenosis after it completed the ultrasound.

23. The Trust explained it was an expert radiologist that did the ultrasound, but they were not a paediatric specialist. The Trust also stated that ultrasound does not provide a definitive diagnosis of pyloric stenosis. It said overall clinical presentation, together with blood results, should be considered and reviewed if someone’s symptoms continue.

24. Our adviser referred us to the AJR study. This identifies the key components of diagnosing pyloric stenosis in infants. The study concluded the best model for diagnosing pyloric stenosis has three factors. These are the age when the infant’s vomiting started, the pyloric length and the pyloric diameter. This means we can reasonably say that ultrasound is a key part of the diagnostic process.

25. In O’s case, his vomiting started when he was less than five weeks old, he had a pyloric length greater than 14mm and a pyloric diameter greater than 10mm. Our adviser explained these signs showed a likely diagnosis of pyloric stenosis. But, the Trust did not think this was the case. Given the evidence we have seen, we have decided this was a failing.

26. We then turned to what the Trust should have done at this point. Given O’s abnormal pylorus and because he had been vomiting since he was less than five weeks old, our adviser explained the Trust should at least have referred him to a paediatric radiologist.

27. The GMC guidance says to give clinical care doctors must, ‘refer a patient to another suitability qualified practitioner when this serves their needs’. The Trust confirmed the radiologist who did the ultrasound was not a paediatric specialist.

28. Based on this, we have found the Trust took the incorrect measurements from the ultrasound on 19 April and did not think O had a likely diagnosis of pyloric stenosis. We have also found that the Trust failed to refer O to a paediatric specialist in line with the GMC guidance.

Impact

29. We next looked at what impact the failings we found had. When the Trust discharged O on 20 April, he became dehydrated and Mrs P believed he would have died if she had not taken him back to hospital. As Mrs P did take him back to hospital and he was treated, fortunately there was no medical impact. This does not remove the emotional impact on Mrs P.

30. Mrs P described her feelings about what may have happened if she had not taken O back to hospital. She says it was traumatic for her and it has been very difficult to process. The initial emotional impact only lasted for a day (because she took O to hospital the day after he was discharged and he got treatment). Mrs P explained this was then made worse because she struggled to get over the stress it caused.

31. Our Principles say public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration (fault) or poor service.

32. The Trust did not identify any failings with the ultrasound it completed on 19 April or in not considering a likely diagnosis of pyloric stenosis and taking reasonable steps to investigate it further. It has said it was good practice to do the scan again after Mrs P took O back the next day. We have decided the Trust has not taken appropriate action to put right the impact of the failings in line with our Principles.

1. Mrs P is understandably concerned about her son’s (who we will call O) diagnosis. We can see why this was distressing and traumatic for her. We are sorry to hear about what they have been through.

2. During our investigation, we found failings in the Queen Elizabeth Hospital King's Lynn NHS Foundation Trust’s (the Trust) care and treatment. We found the Trust took incorrect measurements when doing the ultrasound on 19 April 2022. Given the ultrasound results, we have decided the Trust should have referred O to a paediatric specialist for further investigation. It seems the scan showed a likelihood of pyloric stenosis (this is the narrowing of the pylorus, the opening from the stomach, into the small intestine).

3. Mrs P is concerned that as a result of the Trust’s actions her son became dehydrated and she believes he would have died if she had not taken him back to hospital. We are reassured the Trust’s actions did not have a medical impact. This is because Mrs P returned O to hospital the next day. We have found an impact of severe emotional distress. We uphold Mrs P’s complaint.

4. We recommend the Trust creates an action plan to prevent the same failing from happening again.

33. We recommend that:

• within eight weeks of the date of our final report, the Trust should provide an action plan to show how it will reduce the chance of the same failings happening again.