North Tees and Hartlepool NHS Foundation Trust

8. Miss P complains about the experiences herself and her son, F, had at the Trust between 9 and 11 July 2023.

9. Miss P says that the Trust:

• failed to follow national guidelines, and did not uphold her parental rights by continuing to try and take blood from F after she asked staff to stop • failed to take blood from F properly, meaning that it homologised, could not be used, and therefore had to be taken again • failed to provide treatment to F for an unexplained rash, an inflamed throat and constipation during his admission and instead focussed on its safeguarding concerns • claimed that she harmed her son by using her thumb to cause bruising on his cheek • made errors in its safeguarding proceedings by: • initiating safeguarding proceedings in a multi occupancy room where other patients could overhear • starting proceedings without informing her, therefore failing in its duty of candour • gave her and her partner out of date leaflets about the safeguarding procedures • did not include their other children in the safeguarding plan when it should have done • did not invite all of the relevant professionals (for example F’s childcare provider) to the multi-disciplinary meeting about F’s case, nor did it inform her of the outcome of the meeting when it should have done.

10. Miss P says that the impact to her has been:

• severe trauma and distress to herself when she witnessed staff attempting to unnecessarily take blood from F on multiple occasions • ongoing distress due to it raising safeguarding concerns and the misinformation in the process which lead to herself and her partner worry about doing things wrong and facing further repercussions • distress as she felt that her parental concerns about F’s health were not being listened to nor were her parental rights being upheld when she asked staff to stop trying to take blood from F • she has lost faith in the NHS and is in constant fear of being incorrectly accused of harming her son again • worry that people on the ward overheard the Trust initiating safeguarding proceedings and how this may impact her career in the NHS.

11. Miss P says that this has significantly impacted on her daily life. She is on the waiting list for suspected post-traumatic stress disorder (PTSD) and her mental health has declined as a result of her experiences at the Trust. Miss P explained that she has now left her job in the NHS as she found herself constantly reminded of her experiences while at work and this was distressing for her.

12. Miss P says that the impact to F has been:

• physical injuries when the Trust attempted to take blood from his hands and feet. These injuries lasted a couple of weeks • a delay in his treatment at the Trust as its poor clinical practice meant that the blood they took haemolysed (a red blood cell burst) and it could not be analysed as quick as it should have been • caused him additional pain and suffering as it did not administer his prescribed medication as it was too focussed on its safeguarding concerns • F could not go to his childcare for six weeks because of the ruling after the safeguarding concern was raised that he had to be supervised by two people at all times. This meant that he missed out on key social interactions and development during this time and also had an impact to her and her partner, who had to alter their schedules and take time away from work to ensure that F was cared for in line with the safeguarding reports recommendations.

13. Miss P told us that the actions of the Trust impacted her whole family. She explained that her older son who was a teenager at the time of the incident found it distressing to have social services visiting the house and questioning them. Miss P explained that her older son has since had therapy which was partly to help him with the impact of these events.

14. As an outcome to her complaint, Miss P is seeking service improvements and a financial remedy.

15. Miss P attended A&E at the Trust with her son, F, on 9 July 2023 as F was experiencing excessive sweating, vomiting, a cough/ wheezing, lethargy, urine retention, constipation, had a rash and was constantly holding and banging his head. Miss P was concerned about F’s symptoms and said that he was crying more and being more clingy to her than usual.

16. In A&E F’s observations and history were taken. It was identified that his heart rate and respiratory rate were increased. The Trust made the decision that F needed bloods taking.

17. Later that evening blood was taken from F after two attempts. Following this a physical examination was performed on F and at this time they were informed that some of the previous bloods were insufficient so required repeating. The Trust told Miss P at this time that the bloods they had managed to test were normal and if the further bloods were also normal, they would be discharged. The Trust staff again obtained blood from F.

18. When the second set of bloods were being taken from F, Miss P mentioned to the doctor that F had some bruising. The doctor explained that they had identified this and had reported it to their consultant to review. They also said that this, alongside the head hitting behaviour that F was performing were concerning. At this time Miss P expressed her concern that F had pain in his head, such as from a brain tumour.

19. On 10 July 2023 at around 8:00am, F was admitted to the children’s ward.

20. Later that day F had his oxygen saturation, blood pressure and pulse tested before he was reviewed by nursing staff and a history was taken again. At this time, at around midday, Miss P pointed out the bruising to the staff. The staff then told Miss P that they had safeguarding concerns about F.

21. On 11 July 2023 F was sent for a CT scan. Following this Miss P was contacted by the safeguarding team who informed her that the safeguarding meeting was finished, and that she would be contacted by a social worker.

22. F was booked for a second scan, 14 days after his initial one. Miss P explains that she was told that until they had the results of this second scan, F would need to be accompanied by two adults at all times.

23. That afternoon, F had further blood tests. Miss P explained that the staff had to try on multiple occasions and struggled to take blood from F.

24. Following this, Miss P asked if she could have some of the medication that was offered to F in A&E to help with his constipation. Staff agreed to provide F with this.

25. F was discharged home on 11 July 2023.

Blood homologising after it was taken from F

29. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

30. Miss P explained that when the Trust initially took blood from F, it homologised and it therefore had to be taken again. Miss P told us that the Trust struggled to take blood from F, and had to try on his feet, meaning that he had multiple bruises on his arms and legs that she feels could have been avoided.

31. Miss P explained that she is aware that poor clinical practice can result in blood homologising. She feels that it was the poor practice of staff at the Trust that caused the blood to homologise. We understand why it will have been difficult for Miss P to see F in distress when the Trust attempted to take blood from him on multiple occasions.

32. In its complaint response on 22 December 2023 the Trust said that repeat samples are often unavoidable and apologised for any distressed experienced by Miss P or F as a result of this.

33. F’s medical records show that he had blood taken on two occasions on 9 July 2023. They explain that on the first occasion, the blood homologised (clotted), and this meant that it had to be taken again as the blood could not be used for testing. There are no records that discuss the specific way in which the blood was taken.

34. The records and the information provided by Miss P indicate that F found having blood taken difficult and would get increasingly distressed throughout the process.

35. Our paediatrics adviser explained to us that blood homologising is not uncommon and can sometimes happen just as part of the process of taking blood, and not only as a result of poor clinical practice.

36. They continued that homologised samples are much more common in young children, such as F. They explained that young children are more likely to struggle against blood being taken and have a greater percentage of body fat and therefore less viable veins meaning it is harder to take blood from them.

37. The guidance on drawing blood explains that if a blood sample is poorly collected the patient may need to undergo the inconvenience of repeat testing. It outlines that one of the major issues resulting from difficulty in collecting is blood homologising.

38. Although the notes indicate the amount of times that the Trust attempted to take blood from F, they do not explain the exact process that staff used when the blood was taken from F. We cannot reach a conclusion on the quality of the process that the Trust used when it took blood from F, as the exact process was not recorded.

39. We can however, conclude that it is common that there are issues with taking blood from small children, which may result in the blood being poorly taken, and that may result in it homologising and needing to be repeated.

40. Taking into account the information provided in F’s medical records, the information given by our paediatrics adviser, and the guidance on drawing blood, we can conclude, on the balance of probabilities, that the issues with F’s blood homologising were more likely than not, as a result of the staff having difficulty taking blood from a small child, rather than poor clinical practice. We therefore should not consider this complaint further.

Claims that Miss P had harmed her son

41. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

42. Miss P told us that the Trust initiated safeguarding procedures against her due to its belief that she had harmed her son by pushing her thumb into his cheek to create bruises. She said that a member of staff held their thumb to her sons face to indicate how she may have harmed him.

43. Miss P said that she feels that the safeguarding claim was unwarranted and inappropriate, and found the suggestion that she may have harmed her child distressing.

44. F’s medical records indicate that when he attended A&E on 9 July 2023 staff were concerned about bruises on various areas of his body that they saw during their initial examination of him.

45. The Health and Social Care Act explains that where any form of abuse is suspected, occurs, is discovered, or is reported by a third party, the provider must take the appropriate action.

46. The Trust’s safeguarding policy reiterates this and explains that if staff have any concerns that potential harm may have come to a child, they should take the appropriate action to raise these as safeguarding concerns without delay.

47. In line with the Health and Social Care Act and the Trust’s safeguarding policy, as the Trust had concerns about F’s safety due to the bruises, the Trust followed the correct procedure in raising a safeguarding concern when they considered that harm may have come to F. We will therefore not consider this complaint further.

Started safeguarding procedures without informing Miss P

48. Miss P explained that when F was admitted to hospital on 10 July 2023 she was under the impression that he had been admitted as he needed monitoring. However, she was later informed that the reason for admission was to monitor him as staff had safeguarding concerns. Miss P feels that they should have been informed of this on admission and that the Trust failed in its duty of candour by not doing so.

49. F’s medical records show that when he was seen in A&E on 9 July 2023 he was seen by an ‘out of hours’ team. The records explain that the staff who saw F were conducting tests to eliminate any potential medical conditions. As part of this process, they contacted the on-call consultant to discuss the case. The on-call consultant agreed with their plans for admission to monitor F as part of their investigations into his symptoms, and their safeguarding concerns.

50. Although the staff did seek the advice of the on-call consultant, the symptoms that F was presenting with were not severe enough for the consultant to come in, and it was arranged that he would be admitted for monitoring and a consultant could see him in the morning to assess the situation further.

51. The GMC guidance says doctors should consult colleagues or seek advice from your supervising clinician, where appropriate and refer a patient to another suitably qualified practitioner when this serves their needs.

52. Our safeguarding adviser explained that in an ‘out of hours’ consultation, such as this one, it was the correct practice for the staff to contact the on-call consultant, to ask for their advice on the situation. It is standard practice in many situations to admit a patient to allow for the consultant to fully assess the situation in the morning before making a final decision about any ongoing care.

53. The records indicate that the staff noticed the bruising on F during their initial examination of him and did note a safeguarding concern at this time. The records then explain that the staff were keen to conduct further investigations to rule out any potential medical cause of the bruising. Although there were initial safeguarding concerns at this time, this was not the only reason for F’s admission.

54. Although staff could have informed Miss P of the safeguarding concerns prior to his admission, as F was also being admitted for concerns about his health, and to investigate any potential medical cause of the bruising, it was appropriate, and in line with the GMC guidance, for staff to admit him on this basis, and then wait to confirm their concerns about safeguarding with the consultant in the morning before proceeding.

55. Therefore, as the safeguarding procedures were only officially started the following morning, after the consultant review, and after any medical cause for the bruising was ruled out, and Miss P was informed at this time, we have not seen any evidence to suggest that the Trust formally started safeguarding procedures without informing her. We will therefore not investigate this complaint further.

Communication around safeguarding proceedings

56. Miss P told us that there was a lot of miscommunication about the safeguarding proceedings. Miss P said that she was not told the reason for F’s CT scan being due to the safeguarding concerns.

57. The records show that Miss P was told about the safeguarding proceedings on 10 July, when a consultant had reviewed the situation in person. The consultant explained to Miss P that they wanted to do further investigations for safeguarding that would include a CT scan and a skeletal survey.

58. The notes then later explain that the family were unaware that the CT scan was for safeguarding. It is noted that a member of staff was asked to go and talk to the family to ‘clear up any miscommunication about the CT scan’.

59. There are two differing notes in F’s medical records about if Miss P was told that safeguarding was the reason for the CT scan that F was receiving.

60. We have therefore considered the information provided by Miss P, and the information provided in F’s medical records, and feel that we would be unable to reconcile the differing accounts through any further investigation.

61. Although this does not mean that we do not believe Miss P’s account, we do not feel that there is sufficient evidence to allow us to make a decision on if Miss P was informed that the reason for the CT scan was safeguarding or not.

62. As there are two conflicting accounts of what happened here, and there is no further evidence we can gather to help us reach a decision, we consider that we would not be able to reach a satisfactory conclusion so there would be no value in taking this forward for further investigation. Therefore, we should not look into this matter further.

Failure to communicate about the panel meeting, tell Miss P the outcome of the meeting, and to invite all of the relevant professionals to this meeting

63. Miss P also told us that the Trust undertook a panel meeting to discuss the case on 19 July 2023. Miss P said that she was not informed that this meeting was taking place or of the outcome of it. She told us that she feels that this shows the Trust failing in their duty of candour. She said this was distressing for her, as she did not have clear information about how the safeguarding proceedings were going.

64. Miss P told us that when a strategic meeting was held about F’s safeguarding case, the Trust did not seek the input of F’s childcare provider. Miss P feels that it should have done, given that it had input from her other son’s school.

65. Our safeguarding adviser explained to us that it would be the responsibility of children’s social care to arrange the MDT meeting, and that the Trust would not have input into which professionals would be invited to that meeting. It would be children’s social care’s decision of which professionals they felt it needed input from.

66. Our safeguarding adviser also explained to us that it would be the social workers responsibility to tell Miss P about any meetings taking place.

67. The Safeguarding Children Guidance explains that the local authorities children’s social care organises the strategy meeting to decide whether to initiate further proceedings on the basis of the safeguarding concerns. It explains that this should include ‘children’s social care, police, health and ‘any other relevant body’. There is no part in the guidance that says that childcare providers must be invited.

68. The guidance then explains that it is children’s social care who decides which additional practitioners to invite, so it would be their responsibility to invite a childcare practitioner if they considered this helpful, not the Trust.

69. As the Safeguarding Children Guidance is clear that it is social care’s responsibility to organise the meeting, invites all parties, and inform the family about the meeting and outcome, we do not consider the Trust had any responsibility to do this. Therefore, we should not look into this matter further.

Failure to provide F with treatment for the symptoms he presented with

70. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

71. Miss P explained that when F attended hospital and through his admission she does not feel that the Trust treated the symptoms that he presented to A&E with appropriately, and that it was too focussed on the safeguarding proceedings rather than supporting F with his health concerns.

72. F’s records show that he attended A&E at the Trust on 9 July 2023 as he was experiencing excessive sweating, vomiting, a cough/ wheezing, lethargy, urine retention, constipation, had a rash, and was constantly holding and banging his head. Miss P explained that she was concerned about F’s symptoms and said that he was crying more and being more clingy to her than normal.

73. The records then show that in A&E staff assessed F when he attended. The notes show that they were aware of Miss P’s concerns about F’s symptoms. A&E staff felt F may be suffering from a viral infection and wanted to investigate his symptoms further. It made the decision to admit him on this basis alongside the potential safeguarding concerns.

74. Our A&E adviser explained that the purpose of A&E is to identify if a patient needs to be admitted or discharged. It did so in this case and concluded that F needed to be admitted for further investigations.

75. The records continue to explain the treatment that F had while he was an inpatient. The records show that F had a blood and urine sample taken, to test for any potential infection, and a neurological exam. Our paediatrics adviser explained to us that a blood and urine test would identify if there were any issues with his liver or kidneys, or if he had any other type of infection.

76. The prescription records show that the Trust restarted F on movicol (a medication for constipation) and prescribed him difflam (a medication to treat a sore throat).

The records also show that F was booked in to have a CT scan due to the safeguarding concerns.

77. Our paediatrics adviser explained to us that the Trust investigated F’s symptoms through blood and urine testing. They also said that as F was already booked in for a CT scan for the safeguarding concerns, this would also address the potential neurological concerns that Miss P had, as any issues would be picked up on this scan.

78. Our paediatrics adviser explained that the results of these investigations showed no signs for concern and so the conclusion was made that F was likely suffering from a virus. They told us that at this stage, a patient would be discharged home, as there would be no further treatment for this that required an inpatient stay.

79. In F’s case due to the safeguarding concerns, he was kept in for further monitoring on this basis. Our paediatrics adviser concluded that there was nothing further that the Trust could have done to address F’s symptoms.

80. Good Medical Practice explains that practitioners should listen to patients, recognising their knowledge and experience and acknowledging their concerns. It also says that they should adequately assess a patient’s condition, taking account of their history and symptoms and promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

81. In line with Good Medical Practice the Trust listened to Miss P’s concerns about F’s symptoms, and that his current condition was not normal for him. They assessed his condition and then completed blood, urine, and neurological tests, and a CT scan was carried out to investigate his symptoms. It also prescribed medication to address his constipation, and sore throat.

82. Taking all of this into account, we consider that the Trust acted in line with Good Medical Practice, and do not consider that the Trust needed to do more than it did to address F’s medical symptoms. We therefore should not consider this complaint further.

Failure to stop taking blood from F

83. Miss P told us that staff found it difficult to take blood from F and had to attempt to do so on multiple occasions. She said that F was becoming increasingly distressed, and she asked staff to stop but they did not do so.

84. The medical records show that the Trust attempted to take bloods from F on the evening of 9 July 2023. After the first attempt, Miss P was informed that the bloods had homologised and therefore needed to be taken again. The records show that Miss P and her dad, F’s grandad, were present at the second attempt at taking bloods.

85. The records explain that initially, Miss P was in the room holding F while staff attempted to take blood from him, however when he became distressed, she decided to leave the room, and her dad took over holding F.

86. The records indicate that as F was becoming more distressed Miss P came back into the room and asked staff to stop taking the bloods, however, they informed her that they needed to get the sample and continued attempting to do so. Shortly after this the records explain that Miss P’s dad then asked the staff to stop as F was continuing to be distressed. After Miss P’s dad asked, the Trust stopped attempting to take the blood.

87. Miss P told us that she found this distressing and felt that the Trust were not upholding her parental rights by not listening to her and stopping when she told it to.

88. GMC Good Medical Practice says that staff must ensure that they are ‘listening to patients, recognising their knowledge and experience of their health, and acknowledging their concerns.’

89. In not listening to Miss P when she asked them to stop taking blood, the staff were not acting in line with Good Medical Practice. This is an indication of a failing. We have considered the impact of this and the remedy the Trust has agreed to put this right below.

Errors in safeguarding proceedings

90. Miss P explained that when the Trust told her about the safeguarding proceedings, it did so in a multi occupancy room with other patients and their families being able to hear. Miss P said that this was distressing and made her worry about the impact on her career as a midwife in the NHS.

91. In its complaint response on 22 December 2023 the Trust explained that it should not have had the conversation with Miss P about the safeguarding proceedings in a multi occupancy bay. It said that this should have taken place in a private room and it apologised for this.

92. Miss P also told us that the Trust gave her out of date leaflets which explained the safeguarding process. Miss P said that this added to the distress of the situation, as she did not want to do something wrong and be penalised for it, due to being in receipt of out-of-date information.

93. Miss P provided us with a copy of the information leaflet she received which is listed as being due for review in ‘Summer 2020’. Miss P was given this leaflet in July 2023.

94. In its complaint response on 22 December 2023 the Trust explained that it agrees that some of the information leaflets that Miss P was provided with were due for review. It said that all leaflets have since been updated.

95. Miss P also told us that when the Trust provided her with its safeguarding plan, it did not include her partners child in this, despite him staying with Miss P and her partner regularly. Miss P said that this contributed to the distress and confusion, as a healthcare professional herself, she was aware that he needed to be included and she did not want to be penalised for the Trust’s mistake in not including him.

96. In its complaint response on 22 December 2023 the Trust explained that it agrees that it should have included her partners son in the safeguarding plan, and it has since updated its electronic system to add this as a prompt to ensure that this information is included if needed.

Remedy

97. As we have not seen any indications of failings in the Trust initiating the safeguarding referral or in how the Trust took the blood or the care provided for F’s symptoms, we cannot link all of the impact that Miss P is claiming to the indications of failings that we have seen.

98. We can say that the failings made an already difficult time more distressing for Miss P and her family and that it is understandable why she would worry that people on the ward overheard the Trust initiating safeguarding proceedings and how this may impact her career in the NHS.

99. We can also say that her and her partner were caused ongoing distress due to the misinformation in the process which led to herself and her partner to worry about doing things wrong and facing further repercussions.

100. We can see why these failings will have had a profound impact on Miss P and her wider family.

101. We also consider that not listening to her when she asked staff to stop taking blood from F will have been distressing for Miss P and that she felt that her parental rights were not being upheld.

102. Our NHS Complaints Standards say organisations should offer fair remedies to put things right and identify learning and use it to improve services. They also say that organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

103. As part of our process, we consider attempting a resolution where it appears that, with minimal intervention, we could achieve a satisfactory result for the complainant. This could include asking an organisation to consider service improvements.

104. We contacted the Trust to discuss this. The Trust agreed to write an action plan which addresses the failings and sets out how it will ensure learning and improvement in the areas that we have seen indications of failings in. It has also agreed to provide Miss P with a financial remedy of £700 in recognition of these failings.

105. We asked the Trust to ensure that this action plan explains how it will reinforce with clinical staff their obligation to listen to, and act on, parents’ concerns during procedures. This needs to include clear guidance on pausing or stopping procedures when a parent withdraws consent or requests a stop, unless there is an immediate and serious risk in not proceeding.

106. We also asked the Trust to set out how it will ensure that safeguarding discussions with patients and families always take place in an appropriate, private setting and what changes it has made to local protocols, staff training, or monitoring arrangements.

107. We also asked it to provide details of how it will ensure that all children who live in, or regularly stay at a home, are consistently included in safeguarding plans, including the electronic prompts and any additional checks or staff training.

108. We also asked it to provide further information on the systems that have been put in place since Miss P’s complaint to ensure that information leaflets, in this case specifically relating to safeguarding, are kept up to date, how review dates are monitored, and how out of date materials are removed from circulation.

109. The Trust has agreed to write an action plan to take learning from the complaint and to improve its service. It has also agreed to provide Miss P with a financial remedy. This is in line with Our NHS Complaint Standards and is the outcome that Miss P was hoping to achieve from this complaint. As such, we consider that this issue is now resolved and we will not be taking any further action.

110. We are sorry to hear about the experiences that Miss P and her family had at the Trust. We can understand why an already difficult time was made more distressing due to the failings made by the Trust. We would like to thank Miss P for taking the time to bring her complaint to us.