This report alerts providers to key findings and actions following review of delayed recognition of lack of red reflex in a newborn. The findings from this case extend across care settings, specialties and national guidance. The organisation involved in this case has identified actions to reduce the risk of recurrence and elevated its concerns to the relevant professional bodies.
We advise providers to consider this report, and whether recommendations made might apply to their own systems.
This report is relevant to:
- midwives, maternity and paediatric care providers and paediatric staff completing newborn assessments
- primary health care and general practice clinicians
- ophthalmology clinicians
- quality improvement, clinical risk and patient safety managers.