Newport: Radiology failures led to baby placed into care

Radiological oversights and social service decisions wrongly resulted in a six-month-old premature baby being left in care for 26 days, according to a family.

The mother of two shared her story after reading about another Welsh family’s experience.

She said specialists should have been involved earlier and felt “punished”.

Newport Social Services declined to comment on individual cases, but said no child was taken into care without careful evaluation.

Aneurin Bevan’s health board said it was bound by protective procedures.

The parents – whose names are Sarah and John – brought their premature son to the Royal Gwent Hospital in Newport on January 19, 2020.

The boy – named Thomas – was accidentally dropped on the floor while he was being changed and on the advice of NHS Direct they took him to the Royal Gwent.

“Because he was born prematurely with forceps and his head was up for a while after birth, I was worried it might be related as it took a few months for him to have a normal shape.”

CT scans were taken the next day, then they were given a full physical of a full skeletal exam, blood tests and a retinal test (for his eyes).

The skeletal examination with 30 x-rays was taken on January 21st.

The next day the family was informed that there was a discrepancy on his left shin and later that same day that a patch was found on his seventh left rib.

Police and social workers were called in.

Social workers said they must willingly give up their child in order to retain parental rights and be able to visit their son.

Sarah said: “We knew he wasn’t injured. They thought it was an old injury on his leg and something on his rib and we wanted to know why.

“I had never left him alone except for two hours with my mother since I had him.”

Recalling that day, she said, “He belonged next to me. It felt like he died when we left the hospital without him.”

Since they now shared parental rights with the local authority, many day-to-day decisions about him have been overturned.

“I felt like I was being punished. It was terrible. I was told not to pack any clothes for him as the caregiver would have everything.

“I insisted he wear his clothes, I wanted it to be food I had provided, I wanted him to stick with my milk so we hired a pump.”

The only choice she was allowed was to continue breast milk.

“He was only six months old and had very little to eat at night and when he came back he had three meals a day.

“I had asked that he not eat meat because I’m a vegetarian … I was told it was none of our business and he had to have meat.”

For the next three weeks they had to visit their son at a contact center in Newport.

“We had to sign a document that said we would not show up drunk, we would not hurt our child if we were there, we would not insult the contact worker, we would not take drugs there, we would not drink alcohol take us

“It was a different world. That wasn’t something we participated in,” she said. However, she said the contact center staff were “brilliant”.

During this time, the family had to wait for a second skeletal exam on February 4th.

“On the second X-ray – the radiologist – they both said there was nothing on the rib, it must have been a shadow. They asked if he cried when the X-rays were taken. He was pinned to a metal by two strangers: he was crying, he had no idea what was going on.

“Rib was written off. But they said the leg is the same.

“At the time, I didn’t realize that a regular baby radiologist couldn’t look at baby X-rays. I didn’t know there was anyone more qualified to look at them.

“So they ended up sending her to a specialist in Cardiff – they said it was a pediatric radiologist for someone trained to look at bones in babies.

“They were sent away.

“The results said there was no abnormality. It said he was absolutely fine for his age.”

Although he was told this on February 6, social services wanted a hard copy of the report. Copies of the report sent by email or fax will not be accepted.

“Then they decided they wanted to look into our medical background. They could have done that before this report.

“By the end, I felt like they were trying to justify why they did it,” Sarah added.

By February 11, social services had both the parents’ medical records and the radiology specialist’s report. However, Newport Social Services then wanted to speak to the consultant who wrote the report.

A legal hearing held the following day concluded that Thomas could not come home until a care package was in place and he was likely placed on the child protection register.

However, the care package would not be ready until the following week.

But a week later, on February 17, the family was reunited and as they had moved to another part of Wales the care package was not ready.

A child protection meeting held on March 6 unanimously agreed that Thomas did not need to be included on the register.

At that time, the family decided not to lodge a complaint with the authorities as they wanted to put the experience behind them, so the Ombudsman did not intervene.

Sarah said: “I wanted to get over it. It was only recently when my daughter was that age that I hit rock bottom and I thought I’d never get over it.

“Back then, we listened to Baby P all the time [the controversial case of the 17-month-old baby who died in London of a series of injuries in 2007] and they kept saying it was in the child’s best interest; it was in his best interests, so everything was justified.

“But actually it should be in his best interest to have consulted the specialist much earlier and not treated him.”

Newport Council said: “We cannot comment on individual cases, but no child is taken into care without careful consideration of all the circumstances and such complex decisions are not taken lightly.

“It is an inter-agency process, supported by expert medical advice led by paediatricians, and every effort is made to ensure a child is safe in the family home once a concern is raised. This is done as quickly but as thoroughly as possible.

“We are sure that the public would expect this. We would be rightly criticized if a child were seriously harmed for failing to act in accordance with legal protection procedures.

“We recognize that when a child is placed in care it is distressing for parents, but there are instances where parents are comfortable working with us and retaining parental responsibility.

“Wherever possible, parents can visit their child regularly, sometimes daily, to continue the contact and bonding.

“We always act in the best interest of the child. Unfortunately, we are all too familiar with tragedies that have happened and made headlines because a child has not been protected in the way we would all hope.”

Aneurin Bevan Health Board said: “These situations are inherently emotional and distressing, but the Health Board is bound by national safeguarding procedures that must be followed to ensure child protection and avoid harm.

“The management of such cases is coordinated and guided by the social services from a protection perspective with the active participation of clinicians and pediatric advisors.

“The radiological element is part of the overall examination and the radiologists have no contact with social services and are solely involved in imaging.

“The radiological examination is called a skeletal examination and there is a standard requirement that the skeletal examination must be repeated 14 days later after the initial imaging before a radiological diagnosis can be completed.

“In the health authority, standard practice is for all skeletal exams to be double reported by two consultant radiologists specializing in pediatric imaging, with the option for a third reading after the second imaging is completed regionally at 14 days.

“The full completed report is then fed back to the senior pediatric team for discussion with the interagency team in conjunction with an overall risk assessment.

“We would encourage the family to make direct contact with the health department so we can ensure they get the full information and feedback they are looking for.”

Although the Ombudsman for Wales did not intervene in this particular case, he said he found 16 individual complaints about radiology services between 1 April 2017 and 31 March 2022, with three cases confirmed and a fourth partially confirmed.

The Ombudsman for Wales said: “We do not normally see complaints about radiology specifically, although this service can be a secondary issue in many complaints that reach our office.

“Complaints to us of children wrongly taken into care due to misdiagnosis of X-rays have been very rare over the years.

“Anyone who has concerns about the care and treatment of their child should first raise those concerns with their healthcare provider. However, we encourage anyone who remains unsatisfied with the response to their concerns to contact our office.”

The UK Ombudsman says it has handled 124 x-ray diagnosis/misdiagnosis cases since January 2019.

Parliament and Health Service Ombudsman Rob Behrens said: “X-rays and scans are an important gateway to healthcare.

They can provide both reassurance and the start of any treatment. That is why it is important that they are right. Since January 2019 we have received 124 cases related to X-ray misdiagnosis. In 2021 we published a report, Unlocking Solutions in Imaging: working together to learn from failures in the NHS, which identified shortcomings in the way x-rays and scans are reported and tracked within the NHS.

“These problems are not limited to radiologists, radiologists or imaging services, but relate to the entire system.

“Our report recommends system-wide improvements to more effectively and timely manage x-rays and scans. While some progress has been made, the continued involvement of NHS leaders is critical to achieving meaningful change in the way imaging is managed as part of patient care.”

None of them could confirm whether social services and the police were involved in these complaints.