Learning from Incidences November 2018
A 23 week old baby was admitted to hospital with multiple leg and rib fractures. Baby born in April to a Mum registered with the practice but baby not registered until August.
- Baby did not attend for a new baby check and did not attend for her 1st immunisations until 23 weeks of age;
- No contact with practice from the Health Visiting team regarding this baby. This was despite documentation that the baby had been seen and that mum had mental health issues;
- Social Services contacted duty doctor when the fracture first came to light. It was a busy Monday morning, and the doctor was unable to quickly identify the issues raised above from reviewing the screen.
- Practice to create a scheduled task for Reception Team whenever they code an end of pregnancy on a registered patient. Task will be generated when the baby is 2 weeks old and will prompt the reception team to contact the family to register baby and make appointments for baby check and first scheduled immunisations;
- Report to be created to identify all children who have not attended for their scheduled immunisations. Immunisation lead will contact the families to discuss the reasons for not booking and to encourage them to arrange appointments;
- All GPs will be reminded to use their clinical system Baby Check template, so that a code is added on the record which may be used in reports to identify babies who do not attend;
- The patients’ own GP to review any safeguarding concerns raised in their own time, as a way of checking that the duty doctor has not missed any critical information;
- If patients attend late for registration or 6 week baby check or vaccination, then the patient’s own GP needs to be informed;
- When seeing a mother with post-natal depression or other mental health issues, clinicians should check that baby’s records are up to date;
- Good communication with the HV team should be maintained and if the practice is not informed of issues then a discussion with the team leader would be helpful.