Decision Report 201601244

Summary

Mr and Mrs C complained to us about the treatment they received at an out-of-hours centre where they took their baby on the advice of NHS 24 as he was not feeding well and was blue around his lips. There was a wait to see a GP and the baby went pale and struggled to breathe. The baby was seen urgently by a GP who examined him through his clothing and told Mr and Mrs C to take the baby to the A&E department at Crosshouse Hospital in their car. On arrival at the hospital, the baby stopped breathing and had to be resuscitated. The baby remained in hospital for three days. Mr and Mrs C felt that the GP should have given their baby oxygen and arranged for an ambulance transfer to hospital.

We took independent advice from an adviser in general practice medicine and concluded that the GP had carried out an inadequate examination of the baby as they did not remove the baby's clothing. In addition, we noted that the GP had maintained that they did not administer oxygen to the baby as it would have delayed the referral to hospital. We found that as oxygen was available at the out-of-hours centre, the GP should have administered it to the baby. We also found that it was inappropriate to have asked Mr and Mrs C to have transported their baby to hospital without clinical support. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings in care and treatment which have been identified during this investigation;
• ensure that the GP discusses this complaint with their GP appraiser as part of their yearly appraisal; and
• ensure that the GP considers whether there is additional learning in relation to the initial management of patients with unstable blood pressure. The GP may benefit from the clinical support group in this regard.