A one-day-old baby who suffered permanent brain damage due to blood transfusion errors was highlighted as one of more than a third of clinical negligence cases, which have failed to be adequately investigated, according to a new Health Service report.
Having developed a severe and deteriorating jaundice after 24 hours, the baby urgently required treatment involving a blood transfusion. However, serious mistakes made by a doctor and a nurse who carried out the transfusion led to the baby experiencing breathing problems, and the heart had also stopped.
Despite the presence of a more senior doctor supervising the procedure, mistakes occurred, which caused more blood being removed than was replaced as a result of a ‘lack of balance’ during the transfusion. The rapidly worsening condition and eventual collapse has left the one day old baby with permanent brain damage and severe disabilities needing special treatment and care for the rest of its life.
It was only when the Parliamentary and Health Service Ombudsman (PHSO) began investigating the case that the hospital Trust acknowledged that mistakes had been made, and with such devastating consequences. The Trust later wrote to the parents accepting and apologising for their failures. They also agreed to carry out an in-depth Serious Untoward Incident (SUI) investigation to find out why the failure occurred and to take action to ensure the mistakes would never be made again.
However, the Ombudsman found that the hospital's SUI investigation was "fundamentally flawed and did not identify glaring errors in the conduct and recording of the transfusion, and ignored obvious explanations for what happened.”
According to their recent Health Service report, the Ombudsman found 150 complaints alleging a failure of care had led to patients suffering “avoidable harm” or a loss of life. Of the 28 cases, which should have been investigated by the NHS as a SUI, just over 70 per cent of cases had not been looked at by the hospitals. The Ombudsman also found "significant variation" in the quality of NHS investigations.