A health visitor’s failure to spot a baby had abnormal fluid on the brain has prompted a call for better training and supervision.
Complaints lodged by the mother of tot that the problem was not picked up early enough were upheld by the Scottish Public Services Ombudsman.
It found the condition – known as hydrocephalus – was not spotted because of “failures to appropriately record and interpret” the size of the baby’s head.
The measurement taken at four to six weeks should have raised alarm bells, the watchdog found, but diagnosis was not made until the age of four months.
A GP has already apologised to the mother for not personally checking the charts.
NHS Grampian has been told by the ombudsman to provide further training on the guidelines and “adequate clinical supervision” for health visitors.
The SPSO also found an “unreasonable failure” to properly plan the discharge of a hospital patient.
The man, who was unable to make his own decisions, was discharged to a community hospital “against his family wishes and without relevant documentation”, it reported. He later died a day after being sent home.
A “breakdown in communication” meant medical staff “wrongly informed other staff about the family’s wishes”, the watchdog said.
It said NHS Grampian should apologise and review procedures.
A spokeswoman for the health board said: “We fully accept the ombudsman’s findings and have implemented their recommendations in both of these cases.”