NHS Fife has apologised to the family of a child who died after a watchdog found that their abnormal chest x-ray results were missed.
The Scottish Public Services Ombudsman (SPSO) said that an outpatient chest x-ray which had originally been reported as normal was abnormal.
The correct result may have helped to diagnose the unnamed child – referred to as ‘A’ – sooner.
The patient later suffered a cardiac arrest and was transferred to another health board for surgery where they died.
Watchdog upheld parent’s complaint over NHS Fife’s care of child
The SPSO upheld a complaint by A’s parent over the care they received from NHS Fife about symptoms of a productive cough, breathlessness and occasional wheeze.
The parent complained about delays to assess, diagnose and treat A’s condition.
They also complained that A had been transferred to another health board for surgery when it was known that intervention would have been futile.
A report by the regulator said that the child received two outpatient chest x-rays due to their symptoms.
The first x-ray was reported as normal but the second showed changes suggestive of pulmonary oedema, a condition in which too much fluid accumulates in the lungs.
Their GP was then advised by a consultant to commence a diuretic, drugs that enable the body to get rid of excess fluids, straight away.
The consultant also told the GP to refer A to cardiology on suspicion of heart failure.
Separately, the child presented at A&E and was discharged with a trial of steroids and an inhaler.
Child suffered cardiac arrest requiring resuscitation before death
The report by the SPSO said: “A was seen at the cardiac function clinic, with the plan being made to see them at the heart failure clinic.
“A’s condition deteriorated before being seen at the heart failure clinic and the GP arranged for their immediate admission to the coronary care unit (CCU).
“A suffered a cardiac arrest shortly after admission requiring resuscitation, and they were subsequently transferred to another health board for surgery where they died.”
During its investigation, the SPSO took independent advise from three clinical advisers, a consultant radiologist, a respiratory and general medical consultant and a consultant cardiologist.
The report said: “We found that the first of the outpatient chest x-rays which had been reported as normal was in fact abnormal and required clinical correlation in respect of A’s presenting symptoms.
“Had this happened, a cardiac cause for A’s symptoms could potentially have been made sooner. ”
The watchdog’s additional findings were as follows:
- NHS Fife failed to use the radiology alert system to flag urgent/unexpected findings during the second x-ray
- The timing of A’s cardiology review was “unreasonable” due to significant indicators of heart failure
- The consultant’s recommendations to commence diuretic and urgently redirect A to cardiology were reasonable
- The child received reasonable care and treatment in the CCU and ICU
The SPSO upheld the parent’s complaint.
NHS Fife ‘deeply sorry’ for shortcomings in care
It ordered that NHS Fife should apologise to the child’s parent for delays in assessing and treating their condition.
The watchdog also made recommendations to the health board regarding the handling of patients presenting with heart failure and identification of abnormal x-ray results.
In a statement, a spokesperson for NHS Fife said: “We are deeply sorry for the shortcomings in the care that this child received.
“Whilst we understand that no words can ease the pain that this family has experienced, we have offered a sincere and formal apology.
“NHS Fife always strives to provide our patients with the highest standards of care, however on this occasion we have fallen short and we are fully committed to implementing the ombudsman’s recommendations in full to ensure that situations like this never occur again.”
