Multiple failings saw child left waiting despite abnormal pulse after seizure

Multiple failings at a Scottish A&E department saw a child left waiting despite having an abnormal pulse following a seizure.

The child’s parent lodged a complaint with the Scottish Public Services Ombudsman (SPSO) following the incident.

The parent raised concerns that their child’s heart rate, blood pressure, and temperature observations had not been taken despite being told by a nurse that this had happened.

They also raised concerns about the attitude and behaviour of staff.

In response to the complaint, Forth Valley NHS Board said the nurse had intended to convey that ambulance staff had taken observations.

It was determined by the nurse, after triaging the child, that they could wait for a doctor.

In a further review provided to the ombudsman, the board found that records showed that the nurse had made observations.

However, staff who were present at the time concluded that there was “no physical evidence” of the nurse taking them at any point during triage.

The watchdog took independent advice from a qualified nurse when putting together their report.

It was found that observations were not carried out, and there were “failings” during triage in acting on the patient’s abnormal heart and pulse rate.

Record-keeping was also found to have been poor, with records not matching accounts provided by staff, missing or incorrect information, and lack of explanation for discrepancies.

The board was found to have been “inaccurate and inconsistent” in its reporting when providing information to the parent and the ombudsman.

The SPSO recommended that an apology be issued to the child and their parent.

They also recommended a number of changes that should be made to ensure better practice in future.

These include ensuring all documentation is in line with guidance and appropriately triaging patients on arrival to A&E.

A spokesperson for the Forth Valley NHS Board said: Please see the following statement: “We have apologised to the family, and action has been taken to address all of the recommendations outlined in the Ombudsman’s Report”.