Summary
Mrs C complained about how a health board responded to concerns raised by the family of her infant granddaughter (Miss A). The family were concerned about a change in Miss A's behaviour when she was around 17 months old, which they believed were due to possible abuse or maltreatment whilst Miss A was in the care of her father. The family had approached their GP, who referred them to a consultant paediatrician. The paediatrician had examined Miss A, but reported no concerns. Mrs C and Miss A's mother felt that the child had not been properly assessed and that the report produced did not provide an accurate account of the examination.
Miss A was referred to Child and Adolescent Mental Health Service (CAMHS), but the family felt that again Miss A was not appropriately assessed. The family requested a second opinion, but did not receive one. We investigated, and upheld, Mrs C’s complaints that the board failed to respond appropriately to serious concerns raised about a child, and that they unreasonably failed to explain to Mrs C their role and remit in this matter.
This report concerns issues around child protection. I am conscious this is a highly complex and emotive area both for families and the professionals involved. It is important, therefore, to be clear about the remit and scope of the investigation and subsequent report. In this investigation, I have only considered the information provided by the board, in the form of Miss A's medical records. Child protection is a multi-agency responsibility and it should not be inferred from this report that the board was the lead agency with responsibility for child protection. It also should not be inferred that this report proves that abuse was perpetrated on a child. Although I accept the board did not have the lead role in child protection, however, it became clear from the advice provided that there were failings in its involvement for which it should take responsibility.
The failings identified relate primarily to the failure to record and document examination of a child to the requisite standard. Although my office can and does consider clinical judgement, that is not the area that is criticised in this report. I have taken the decision to stress this, in view of the subject matter and to forestall any misinterpretation or extrapolation from the report itself.
In order to investigate these complaints, I took independent advice from a consultant paediatrician and a consultant psychologist. I decided to issue a public report on this complaint due to the evidence that the family have suffered a significant personal injustice as a result of the board's failings. Given the sensitivity of the matters raised in the report, I also decided to anonymise the board in order to protect the identity of the family.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) carry out a review of Miss A's assessments by both the paediatric and psychology services; 8 December 2015
- (ii) include the findings of these reviews in the subsequent appraisals of the doctors who carried out Miss A's appraisals; 29 February 2016
- (iii) remind all staff involved in child protection work of the importance of following current guidance on examining and recording findings when assessing children; 3 November 2015
- (iv) review the investigation of Mrs C's complaint in light of the failure to respond to it fully; 17 November 2015
- (v) review what information is provided to families about the CAMHS service prior to referral, to ensure the reasons for referral are clear; and 17 November 2015
- (vi) apologise unreservedly to the family for the failings identified in this report. 3 November 2015