Decision Report 201205352

Summary

Miss C complained that after her mother's death, a doctor influenced the family's decision not to have a post-mortem carried out, and misrepresented the family's views to the procurator fiscal (PF). In responding to the complaint, the board advised Miss C that the doctor should have immediately reported the death of Miss C's mother to the PF rather than discuss whether or not a hospital post-mortem should be carried out at this stage or a significant event review into events leading up to Miss C's death.

We found evidence indicating that the doctor had appropriately explained to the family what a hospital post-mortem would involve and that this appeared to be in order to help them decide whether or not they wanted one carried out, rather than trying to influence their decision either way. Although the doctor did not follow the correct procedure in reporting the death to the PF, we did not consider there was evidence that he was intentionally misleading the family because he had clearly documented in the medical records and disclosed his concerns about some aspects of the care to them. We noted that a different doctor informed the PF of the death but the PF did not consider that a fiscal post-mortem was required.

We were unable to clearly establish what the doctor said to the family immediately after Miss C's mother died, as there was no independent evidence of this. However, we noted that a record made by the doctor at the time documented that the family were not keen on a post-mortem being carried out and that the PF was told about this in an email. Although we did not uphold Miss C's complaints, we made recommendations to ensure that matters are more clearly understood and explained in future.

Recommendations

We recommended that the board:

• ensure that relevant staff are aware of the situations in which reporting death to the PF is necessary; and
• ensure that relevant staff clearly explain to families the process regarding post-mortems.