ImportanceComplaints and malpractice claims by families on the care of their babies are pertinent issue. Beyond just the financial implications, it involves harm to babies and distress to parents.ObjectiveThe aim was to review published reports of complaints by families on the care of their babies in the neonatal units in order to understand the nature of these complaints and the areas of care that they relate to.MethodsWe considered articles in English, which report on complaints made by families to organisations providing neonatal care. We performed our structured search on AMED, CINAHL, EMBASE, EMCARE, SCOPUS and MEDLINE from January 2000 to December 2020. A total of 378 articles were appraised using eligibility criteria.ResultsA total of 12 articles were included. The most common category of complaint was delayed/incorrect diagnosis. Communication issues were highlighted as a significant category of complaints. The majority of such claims were between the physicians and families. Factors implicated for clinician’s errors that resulted in complaints were lack of clinical and communication training, inadequate supervision of junior clinicians, work culture and hierarchy, not listening to families’ concerns and system failure.ConclusionsThe most frequent categories of complaint reported in our systematic review were delayed/incorrect diagnosis and delayed/incorrect treatment. Organisations should be encouraged to share complaints data as it can facilitate shared learning. An understanding of human factor principles and its role in patient safety is also emphasised in this report in order to optimise patient outcomes and improve experience for families requiring neonatal care.

We present a case of an extreme preterm infant (Baby X) born at 24-week gestation. The echocardiogram showed evidence of hypertrophic cardiomyopathy (HCM) and a patent ductus arteriosus (PDA). There are a number of well-known causes of neonatal HCM including genetic, metabolic and endocrine. PDA is commonly present in preterm infants, and this can contribute to cardiac remodelling and result in cardiac changes mimicking HCM. Furthermore, medications such as steroids can also cause HCM through various mechanisms. A careful consideration of all the different aetiologies for HCM is important for appropriate management of such cases. This report examines the evidence in the literature for the above differential diagnoses and highlights the challenges in diagnosing the underlying cause of HCM in a preterm infant.