Decision report 201202611

Summary

Mrs C's elderly mother (Mrs A) suffered from angina (heart pain) and high blood pressure. She fell at home and was taken to hospital. Although doctors found no bony injuries from her fall, they decided to keep Mrs A in hospital until her mobility improved. When visiting their mother a few days later, Mrs C and her brother found her in a deep sleep and unresponsive. It was suggested that Mrs A had had a stroke. However, when a consultant reviewed her, he suggested she might be having an adverse reaction to pain medication (tramadol - an opiate drug) that she had been prescribed. Mrs A was given another drug to reverse the effects of the tramadol. Although Mrs A's condition initially improved, she developed heart arrhythmia (abnormal heart rhythm) and collapsed and died thirteen days after being admitted to hospital. Mrs C complained that it was inappropriate for her mother to be prescribed tramadol and that the board's staff failed to take timely action when it was evident that she was sensitive to this medication.

During our investigation we took independent advice from a medical adviser. We did not uphold the complaint that the medication prescribed was inappropriate. The adviser explained that elderly, frail, patients can be at risk of chest infections, and opiates such as tramadol relieve rib pain and allow patients to cough properly, decreasing the risk of infection. However, they can also increase sedation and depress breathing. The risks are lower with tramadol than with other such drugs, however, and we found that it was appropriate for this to be prescribed, particularly as Mrs A was not known to have a sensitivity to the drug. Our investigation found, however, that Mrs A's deterioration was caused by a reaction to the tramadol, which could have been identified earlier. We were not critical of a junior on-call doctor who had investigated the cause of Mrs A's symptoms and had sought advice from two senior colleagues. However, we considered that the initial presumption that Mrs A had had a stroke may have led to some lack of consideration of other causes, such as tramadol sensitivity, and we upheld Mrs C's complaint that the board did not act quickly enough in this respect. We found that the subsequent twelve-hour delay before diagnosis would not have had any long-term impact on Mrs A's health, and that there was no link between the prescription of tramadol and her death. However, we recognised that the delay in identifying this issue caused additional distress to Mrs A and her family.

Recommendations

We recommended that the board:

• ask the clinical team to review Mrs A's case and our comments with a view to identifying any points of learning.