Fife hospital missed abnormality in x-ray weeks before child died

A hospital was found to have missed an abnormality in a child’s x-ray results just weeks before they died.

A parent had taken the child to their GP after they developed symptoms of breathlessness and the “occasional” wheeze.

The child was referred to a NHS Fife hospital for two outpatient chest x-rays with the first reported as normal. They were then routinely referred to the respiratory department for further investigation.

During this period, the child also attended A&E where they were discharged with a trial of steroids and inhaler.

Then their second x-ray results showed “significant deterioration” and symptoms suggestive of pulmonary oedema – a condition where too much fluid gathers in the lungs causing issues with breathing.

The parent complained their child had been transferred to the other health board for surgery when it was known that surgical intervention was “futile”.

Following the new results, the GP upgraded the child’s referral to “urgent”.

They were prescribed a diuretic to help their body get rid of excess fluids and urgently referred to cardiology on suspicion of heart failure.

But the child’s condition deteriorated before they could be seen at the heart failure clinic and they were immediately admitted to the coronary care unit (CCU).

Shortly after being admitted, they suffered a cardiac arrest and had to be resuscitated.

Then they were transferred to another health board for surgery but died.

An investigation by the Scottish Public Services Ombudsman (SPSO) was opened after the parent complained that the NHS board failed to treat their child’s condition with the “urgency it required”.

The guardian complained about the delays in diagnosing and treating their child’s condition given that they had attended A&E and received the second x-ray results that showed “significant deterioration” within a four week period.

The parent complained their child had been transferred to the other health board for surgery when it was known that surgical intervention was “futile”.

NHS Fife said the transfer for surgery was “appropriate treatment” for the patient at the time.

The board did not comment on the timings of the cardiology appointments or assessments, however they explained the immediacy of child’s condition was understood at the time of the admission to CCU.

An investigation that sough advice from medical experts found that the child’s first x-ray result showed abnormalities despite being reported as normal.

The watchdog said that had the abnormalities been addressed the child’s symptoms could have been dealt with sooner.

They also found that the board failed to use the radiology alert system to flag the findings of the child’s second chest x-ray.

The SPSO found the child’s treatment when they attended A&E had been “reasonable” as was their GP’s process seeking cardiology advice before giving them a diuretic.

However the timings of the child’s cardiology review was found to be “unreasonable” given there were “significant” indicators of heart failure.

The Ombudsman told NHS Fife to apologise, upholding the parent’s complaint and telling the board it had to change its practices to “put things right in future”.

This included appropriately identifying abnormal findings on x-rays and flagging critical or urgent x-rays using the significant finding alert system.

An NHS Fife spokesperson 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.”