Decision report 201002747

Summary

Mr C complained that a hospital unreasonably cancelled his late partner (Ms A)'s heart bypass surgery scheduled for May 2010. He also complained that the hospital did not take appropriate remedial action following a report commissioned by the Procurator Fiscal's Office.

Our investigation found that Ms A, who had a history of heart and other health issues, had a second heart attack in February 2010. She was assessed and was first admitted for heart bypass surgery in April 2010, in late May 2010. Although the surgery was successful, Ms A developed complications and died five days later.

Our investigation found that the hospital cancelled all elective (non-emergency) surgery in early May 2010 due to the sudden death of a senior colleague of the team who died in the unit on the day Ms A's surgery was scheduled. The hospital decided to cancel elective surgery as members of staff in the unit were affected by their colleague's death.

We took advice from our medical adviser, a cardiothoracic surgeon (a specialist in surgical treatment of organs found inside the chest). Our adviser said that due to the unusual circumstances it was not unreasonable to decide to cancel elective surgery. Our adviser reviewed Ms A's medical notes and was of the opinion that there had been no deterioration in her condition between her discharge and her readmission for surgery. He was of the view, therefore, that the delay had no bearing on the eventual outcome.

Throughout the complaints process the hospital assured Mr C and our office that a 'careful assessment' had been made of the conditions of all the patients who were discharged that day, including Ms A. Our findings did not support those assurances. Our adviser described the discharge entry in Ms A's notes as 'perfunctory and brusque'. We were concerned that the note contained no references to any examination of Ms A, to test results, or to any standard observations such as pulse, temperature, respiration rate etc. Although we did not uphold the complaint about the decision to cancel surgery in early May 2010, we made two recommendations in relation to the failings found in the discharge process and assessment.

On the matter of the report commissioned by the Procurator Fiscal's Office, the adviser said that the hospital's response to Mr C was reasonable. They noted that one issue raised in the report (the level of a blood clotting agent in Ms A's blood three days after surgery) had not been addressed in the response. However, the adviser was satisfied that staff caring for Ms A took appropriate action and that there had been no failure in care and, therefore, no need for any remedial action. The report for the Procurator Fiscal's Office did not find any evidence of service failure and made no recommendations for remedial action. We agreed that no remedial action was required.

Recommendations

We recommended that the hospital:

• review the discharge processes where surgery is cancelled or postponed for non-clinical reasons and ensure that appropriate examinations are made and recorded; and
• reflect on the quality of their responses on the specific issue of the assessment said to have been done before the patient was discharged and issue a written apology for the failings identified.