The family raised their concerns with the Scottish Public Services Ombudsman’s Office for detailed investigation. NHS Highland has now received the Ombudsman’s Report which makes a number of conclusions. One of the findings was that we unreasonably failed to arrange a consultant review to determine what went wrong and what implications this could have.
NHS Highland Chief Executive, Elaine Mead, said: “I offer my personal and unreserved apology and sincere condolences to the family for failing to provide the standards of care they required and the devastating impact this had on their lives.
“I will continue to lead and support colleagues to ensure, as far as possible, that something like this can not happen again.”
Dr Ian Bashford, Medical Director for NHS Highland, said: “I would also like to offer my condolences to the family.
“We welcome the independent review by the Ombudsman’s Office and fully accept the recommendations and will implement them. The care that we provided fell below the standard that we would expect and I would like to offer my sincere apologies for the distress that has caused.
“We have shared the Ombudsman’s Report with colleagues involved in the case. It is so important that we all continue to reflect and learn to make sure, as best as we possibly can, that this does not happen again.”
Notes to editors:
Specific complaints reviewed by the SPSO were:
• unreasonably failed to follow Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines when carrying out Mrs C's amniocentesis procedure (upheld)
• unreasonably failed to inform Mr and Mrs C that Baby A had an abdominal wall defect which was detected at the time of the amniocentesis procedure (upheld)
• unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and Mr and Mrs C were not given the opportunity to hold him (upheld)
• unreasonably failed to arrange a consultant review to determine what went wrong and what implications this could have for a future pregnancy (upheld)
• inappropriately carried out the amniocentesis procedure in Hospital 1, despite an earlier NHS Quality Improvement Scotland audit report suggesting this should not happen (not upheld)
• inappropriately placed Baby A in what looked like a cardboard box (not upheld)