Decision Report 201204978

Summary

Miss C complained that the care and treatment provided to her late mother (Mrs A) was inappropriate after she suffered a third heart attack. Mrs A also had a history of lung cancer and breathing problems. She was admitted to hospital on the Wednesday before a bank holiday weekend and told she would be transferred to another hospital for further investigations and treatment. However, as services were not available over the holiday weekend, Miss C was also told that Mrs A would not be transferred until the following week. Mrs A was treated with blood thinning medication and her condition was monitored. She complained of dizziness and was diagnosed with postural hypotension (where the blood pressure drops on standing) and some of her medication was stopped. On the Monday she developed severe pain in her head and neck which was not relieved by painkillers. When she was examined by a doctor and had a CT scan (a special type of computerised x-ray), it was found that she was bleeding from the brain. Her doctors consulted with a neurosurgeon (brain specialist) who advised that nothing could be done. Mrs A died later that day.

Miss C complained that, given her past medical history, her mother should have been treated as an emergency case for transfer. Miss C also complained that record-keeping was not to an acceptable standard and that while her mother was in hospital she was not properly cared for, including that her pain was not monitored and managed appropriately.

Our investigation, which included taking independent advice from a medical adviser and a nursing adviser, found that the care and treatment provided to Mrs A was reasonable, appropriate and in line with current NHS guidance. The observations and test results in the clinical records showed that Mrs A's condition was clinically stable and there was no indication to treat her as requiring emergency transfer. Mrs A suffered a recognised risk factor of the treatment she was undergoing, but the medical adviser was of the view that the treatment was reasonable, appropriate and timely. There was evidence that Mrs A's condition, including her pain level, was being regularly monitored and addressed. Neither adviser found any deficiency in the medical or nursing records.