14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If we see evidence of this, we look at whether there are signs the events complained about, had a negative effect, which the organisation has not put right.
Safeguarding 15. Mrs O is understandably concerned the Trust did not follow its own safeguarding policy during her son’s admission in June 2023. She told us it did not follow its policy when it delayed a strategy meeting, a CT scan, and a child protection medical.
16. She told us the experience was extremely distressing and the delay in the Trust carrying out her son’s investigations impacted her family’s wellbeing as she had to spend time away from her young daughter whilst her son was in hospital. She told us her daughter now struggles emotionally when her son has any type of appointment.
17. We were sorry to hear about what happened when Mrs O’s son was admitted to the Trust. From what she told us, it is understandable that this experience was extremely distressing for Mrs O and her family given that they had a prolonged stay in hospital with a young baby, and the experience continues to impact them all.
18. The Trust’s policy for safeguarding children says bruising in children who are not independently mobile, including bruises in babies, should raise concern about the possibility of physical child abuse and a bruise or suspicious mark in this group, however small, should be referred to Child Social Services (CSC). After this, the social worker should then arrange a strategy discussion with police and health colleagues to discuss the need for section 47 enquiries (an assessment to see if there is the risk of significant harm to a child).
19. It goes on to say if the threshold for section 47 is met, a child protection medical should be considered. The child protection can only be carried out during a section 47 investigation and the police and the CSC are the lead agency. Investigations should then be carried out including a skeletal survey, neuroimaging (a cranial CT day one post injury), an ophthalmology review, and coagulation testing for bruises.
20. GMC guidelines say doctors must give patients the information they want or need to know in a way they can understand.
21. When the Trust first admitted Mrs O’s son on 13 June due to a small bruise on his arm and poor weight gain, it referred him to CSC in line with its safeguarding policy. Unfortunately, it appears the CSC rejected this referral. The Trust referred him again on 14 June, but CSC also rejected this referral.
22. The Trust escalated it concerns about the need for a CSC referral to its safeguarding lead on 16 June and requested a strategy meeting with CSC. The Trust and CSC held a strategy meeting on 19 June, six days after Mrs O’s son’s admission, and it planned to fully investigate the cause of her son’s bruises.
23. Following the strategy meeting, the Trust carried out X-rays, a CT scan of Mrs O’s son’s head, a skeletal survey, and a child protection medical (a full check up to look for signs that a child or young person has been abused or neglected) in line with its safeguarding policy.
24. Based on the Trust’s policy for safeguarding children, it appears the Trust had to wait for CSC before it could organise a strategy meeting as it is the social worker that should arrange this. The policy also says the police and CSC are the lead agency for a child protection medical so it appears the Trust cannot arrange this by itself without CSC or police involvement.
25. Therefore, it appears the Trust followed its own policy on safeguarding children when it referred Mrs O’s son to CSC, and it waited for it to instigate the strategy meeting. It could not carry out the child protection medical or the investigations until Mrs O’s son’s case had been discussed in the strategy meeting. It then carried out this medical and investigations promptly on 20 and 21 June, following the meeting.
26. Unfortunately, it appears the delay in the strategy meeting and the investigations were unavoidable on the Trust’s part as it had to wait for CSC before it could progress. We have seen evidence to support the fact the Trust pursued CSC to organise this strategy meeting which shows it was being proactive to avoid any unnecessary delays.
27. Our adviser explained that in cases of potential non accidental injury and safeguarding issues, staff should organise strategy meetings and investigations in a timely manner as it is a very stressful time for parents. It appears there was a difference of opinion between the Trust and CSC about whether a strategy meeting was needed and how to progress Mrs O’s son’s case and this caused the delay in progressing meetings and investigations.
28. However, during this time it appears Mrs O and her family were getting mixed messages from CSC and the Trust as both disagreed on how to proceed. Although we have found the delay in the Trust progressing Mrs O’s son’s case was unavoidable, we cannot see any evidence to show it explained why there was a delay to the family. This is not in line with GMC guidance on communicating with patients and giving them information they need or want in a way that they can understand.
29. In its response the Trust apologised for the family’s experience. It acknowledged that the need to carry out a safeguarding medical was disputed and this led to the delay in the strategy meeting and further investigations. It recognised that this meant Mrs O and her son had a longer stay in hospital. However, it does not appear to fully recognise and acknowledge the impact the lack of clear communication had on Mrs O and her family.
30. As we have seen indications that something went wrong with the Trust’s communication, we have considered how this may have impacted Mrs O and her family. She told us the Trust did not communicate in any way with the family about what was happening. She explained that being in hospital took away the family’s opportunity to be at home and bond with her son and daughter and it took its toll on the mental health of the whole family.
31. Mrs O told us she continues to struggle with her mental health and had to have counselling following her son’s admission. It is clear from what Mrs O told us that this was an extremely distressing time for her and her family, and we do not wish to underestimate her experience.
32. Our adviser explained that the Trust should have clearly explained to Mrs O and her family what was happening and why there was a delay in it deciding on how to progress her son’s case. It appears the Trust did not communicate effectively with the family, and this would have added to their distress at an already stressful time.
33. With this in mind, we contacted the Trust to ask if it would be willing to do some further work to try and resolve Mrs O’s complaint. The Trust has agreed to take further action to address the complaint, and we will consider this action later in our report.
34. We recognise Ms O’s experience has caused her a great deal of distress and continues to do so. We hope our report gives her some reassurance that the Trust has taken her complaint seriously and addresses the failings we have found.
Heart murmur 35. Mrs O complains the Trust gave her conflicting information about her son possibly having a heart murmur. She says she was told different things by different doctors and this was confusing. She also says the Trust delayed referring her son to see a cardiologist. She told us this meant she had to wait eight months to find out if he did have a heart murmur or not and this added to the emotional distress she experienced.
36. We were sorry to hear Mrs O’s concerns about how the Trust gave her mixed information when it told her about her son’s heart murmur and how it delayed referring him to cardiology. From what she told us, these concerns clearly added to her distress.
37. As above, GMC guidelines say doctors must give patients the information they want or need to know in a way they can understand. Our adviser explained a heart murmur is a noise heard when listening to the heart. It can indicate a structural problem with the heart but may also be simply because of increased blood flow with no significant underlying structural problem of the heart.
38. The Trust listened to Mrs O’s son’s heart on 13 June, and it heard a heart murmur. It then picked up the murmur again on 15 June. On 20 June, it appears his heart sounds were normal, and the murmur had resolved. However, on the discharge summary, it says her son has a heart murmur and the Trust had requested a follow up appointment with cardiology.
39. Our adviser explained that the records indicate the heart murmur was not very loud and this may mean that some staff could hear it whilst others could not. They went on to say the Trust should have explained to Mrs O what a murmur is and given her advice about any symptoms to look out for.
40. However, we cannot see any evidence in the medical records to show what the Trust told Mrs O and her family about her son’s heart murmur or what advice it gave her. Therefore, it appears it did not follow GMC guidance about giving patients information they want or need.
41. Mrs O also complains the Trust did not action the referral to cardiology despite saying it would. It is understandable that the delay for her son to see a cardiologist alongside the distress the family experienced during his admission due to safeguarding concerns, is likely to have added to an already stressful situation.
42. GMC guidelines say doctors must promptly provide or arrange suitable advice or investigations where necessary and refer a patient to another practitioner when this serves the patient’s needs.
43. As above, the discharge summary says the Trust requested a cardiology opinion for Mrs O’s son when it discharged him on 23 June. However, it did not action this referral until 31 July, approximately six weeks after his discharge.
44. Although GMC guidance does not specify how quickly referrals should be made, it does say doctors should promptly provide or arrange suitable advice or investigations. It appears the Trust did not follow this guidance when it delayed referring Mrs O’s son to see a cardiologist for approximately six weeks.
45. As we have seen indications that something went wrong regarding the Trust’s communication and its delay actioning the referral, we have considered how this impacted Mrs O. She told us how confusing it was to be told conflicting information about her son’s heart murmur, and she had to wait eight months to find out if her son had anything wrong with his heart which understandably, caused her distress.
46. Our adviser explained that it appears Mrs O’s son did not have any heart problems when the cardiologist reviewed him so the delay to be seen does not appear to have had a detrimental impact to his health. However, they acknowledged that the Trust’s lack of communication would have put Mrs O and her family under further stress.
47. Unfortunately, we cannot say how the six-week delay in the Trust actioning the referral impacted the wait for Mrs O’s son to be seen as waiting times vary nationally. However, we recognise that the delay would have added six weeks onto his waiting time to be seen, when the Trust did not action the referral on 23 June. Our adviser said the wait to be seen would have been distressing for the family.
48. In its response, the Trust acknowledged it delayed referring Mrs O’s son to cardiology for six weeks, but it cannot explain why there was a delay. It also apologised that staff did not answer her questions about her son’s heart murmur adequately. It said the standard of care fell below expected.
49. As above, we contacted the Trust and asked if it is willing to do some further work to fully resolve this complaint. It has agreed to take action, and we will consider this at the end of our report.
50. The communication from the Trust and the delay in her son’s referral clearly impacted Mrs O and caused her distress. We hope our report and the information from our adviser helps to clarify any information she was unsure about.
Discharge summary 51. Mrs O complains that when the Trust discharged her son on 23 June, it did not give her discharge papers with the correct information on. She explained that her son went home on home leave for the weekend on 16 June and went back to the Trust on 20 June whereas the Trust documented it as two separate admissions.
52. NHS England says health and care organisations make every effort to keep records accurate, however, occasionally information may need to be amended. It goes on to say that if a patient thinks the information in their records is factually incorrect, they have a legal right to ask for this to be amended.
53. Mrs O shared her concerns with the Trust about receiving two discharge summaries from it on 24 June. She told it she received one summary that said her son was admitted between 13 and 18 June, and another that said he was admitted between 20 and 23 June. The Trust apologised for the mistake and explained it would put an addendum on the summary to reflect the actual admission dates.
54. The Trust has now amended the discharge summary to document that Mrs O’s son was admitted between 13 and 23 June and he was allowed home on home leave. Our adviser explained that the summary with the addendum is now accurate and reflects the admission.
55. Unfortunately, we cannot say why the Trust sent two separate discharge summaries to Mrs O as this is not documented in the medical records, however, we can see that it amended the records when she raised her concerns in line with the information from NHS England. Therefore, based on this information and the information from our adviser, it appears as soon as it was informed of the issue, the Trust amended the discharge summary, and we will therefore take no further action on this complaint for this reason.
Conclusion 56. Overall, we have seen indications that the Trust got something wrong when it did not follow GMC guidance and did not communicate effectively with Mrs O during her son’s admission or promptly refer him for a cardiology opinion. It appears that this led to the distress Mrs O told us about.
57. Our Principles say where something has gone wrong or poor service has led to an injustice or hardship, the organisation responsible should take steps to provide an appropriate and proportionate remedy. When impact cannot be put right, we consider if compensation would address this.
58. The Trust has agreed to pay Mrs O a financial remedy of £900 to acknowledge and remedy the distress she experienced when it did not communicate with her effectively during her son’s admission or promptly refer her son to cardiology. As we saw no evidence of these failings leading to a more severe or prolonged impact, we are satisfied that the Trust’s apology and its offer of a financial remedy are in line with our Principles.
59. Therefore, we are satisfied the actions the Trust has taken to address these mistakes and has agreed to take, are enough to put right those mistakes. It is understandable that Mrs O’s experience has caused her great distress, and we are sorry for this. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance that the Trust has taken her complaint seriously and has agreed to take action to address the failings identified.