Child found to have ‘surprising’ level of medication in system

NHS Fife has apologised to the mum of a youngster who was found with a “surprising level” of an anti-epilepsy drug in their system.

The concerned mother complained to the ombudsman about the care and treatment given to her child at the Victoria Hospital in Kirkcaldy.

The youngster was prescribed various drugs to try to manage their epilepsy, including one named phenytoin, but had later to be treated for an overdose of the drug.

Ms C’s main concern was that her child was not monitored correctly which allowed a high level of the drug to build up. She also complained about the health board’s handling of her complaint.

Upholding both, the ombudsman found that when the dose was increased at a clinic review the youngster was referred for blood tests to monitor its impact.

But this review was not recorded appropriately and there was an unreasonable delay in communicating with the youngster’s GP about it.

“We found that the results of Child A’s blood tests showed a surprising level of phenytoin in their blood, which should have prompted a clinical review.

“We also found that appropriate action should then have been taken, which would have been to repeat the blood tests,” the report said.

The ombudsman said NHS Fife delayed in acknowledging Ms C’s complaint and failed to communicate appropriately with her both during and at the end of its investigation.

Reiterating an apology to the family, NHS Fife chief executive Paul Hawkins said: “We take very seriously all instances where our care may have fallen below our high standards.”

He added the board had reviewed its recording, monitoring and review mechanisms to help ensure it doesn’t happen again.