Decision Report 201300114

Summary

Mrs C had a long history of chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) and as her condition worsened, she was admitted to hospital. After initial treatment, because of a shortage of appropriate bed spaces, she was transferred to a surgical rather than a respiratory ward through a process known as boarding. Mrs C complained that, once there, she began to react badly to the medication she was prescribed but staff on the surgical ward were unable to deal with her concerns. She maintained that she was given too high a dose and that she may have been suffering from side effects. She said no one explained this to her or addressed her concerns.

We took independent advice from one of our medical advisers, and carefully considered all the relevant information, including Mrs C's clinical records. We upheld Mrs C's complaints about the ward transfer and about staff not responding to her concerns. Our investigation found that although Mrs C was transferred to a surgical ward, throughout her stay there she was under the supervision of a specialist respiratory doctor; the nursing care she received was the same as that provided on any other ward with the exception of an intensive care ward; and her care had been reasonable. However, the board had not followed their own policy to facilitate such a change of ward. The investigation also showed that despite Mrs C's concerns that she was given an unusually high drug dosage, she had not, although she may have reacted badly to the dosage she received. However, we did find that staff failed to respond to Mrs C's concerns despite her long experience of taking this drug, nor did they address mental health concerns that had arisen.

Recommendations

We recommended that the board:

• review the decision to board Mrs C to a surgical ward in circumstances that were not in line with their own policy;
• assure Mrs C that she will not be boarded during future admissions unless this is in line with their policy, and her care needs, including potential side effects from treatment, can be met on the ward she is transferred to;
• formally apologise to Mrs C for their shortcomings in this matter; and
• review Mrs C's case notes and consider providing her with a letter so that if she is admitted as an emergency in future, clinicians are aware of the circumstances surrounding the prescription of salbutamol and her assessment of how the increased dose affected her.