Decision Report 201301943

Summary

Miss C's partner (Mr A) was admitted to Wishaw General Hospital with increasing shortness of breath, coughing and wheezing. Medical staff diagnosed that his chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) had got worse and that a toe on which he had recently had surgery might be infected. The next day, Mr A's condition deteriorated abruptly. He had central chest pain and was very wheezy. As there was no intensive care bed available in the hospital, he was transferred to the intensive care unit of another hospital, where he died two days later.

Miss C complained that the board provided Mr A with inadequate care and treatment. We took independent advice on her complaint from one of our medical advisers. The adviser noted that when Mr A was admitted, it was recorded that he had previously been admitted to the high dependency unit in the hospital with breathlessness. Miss C considered Mr A should also have been admitted to the high dependency unit on this occasion. However, our adviser said that it was reasonable not to admit him there, as his condition had been stable at that time. Staff took Mr A's existing health problems into account and the care and treatment provided to him was reasonable and appropriate. A doctor acted correctly in reducing the amount of oxygen delivered when there were signs of a deterioration in Mr A's respiratory function. It was also appropriate for a consultant anaesthetist to intubate and ventilate (pass a tube into the airway and place on a mechanical ventilator to assist with breathing) Mr A in response to his vomiting and low oxygen saturation levels.

Miss C also complained that staff had failed to communicate with Mr A's family adequately. She said that they had not contacted her to let her know that Mr A's condition had deteriorated. However, we found that his deterioration coincided with Miss C's arrival at the hospital to visit him and there had not been time for staff to contact her before this. We did not consider that there were any major failings in the initial period of communication with the family. However, communication with them was not satisfactory when Mr A was stabilised and awaiting transfer to the other hospital's intensive care unit. We also found that the board had delayed in responding to Miss C's complaint. Although we upheld these complaints, we made no recommendations as we were satisfied that the board had apologised and had confirmed that lessons had been learned.