Decision Report 201400384

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) about the care and treatment of his late mother (Mrs B). Mrs B was admitted to Glasgow Royal Infirmary with pain in her side and was found to have a kidney stone. She began taking medication to expel the stone and was discharged home for review in two weeks' time. When she attended for review, although she said she was still experiencing pain, an x-ray did not reveal any obvious stone. Arrangements were then made for a further examination and she was admitted to the New Victoria Hospital for surgery, following a discussion between Mrs B and the consultant in which Mrs B agreed to this. Mrs B was discharged the day after her surgery but later the same day she was admitted to hospital with pneumonia, moderate to severe hydronephrosis (where one or both kidneys become swollen or stretched as a result of a build up of urine) and multi-organ failure. She died a few days later in the intensive care unit.

Mr A was concerned about his mother's care. He questioned whether her previous medical history had been taken into account, whether she had been given the correct antibiotics and whether she should have been discharged the day after her operation.

In considering this complaint, we took independent advice from a consultant urological surgeon, who specialises in problems of the urinary system. We found that it had not been reasonable to operate on Mrs B and that this had not been in her best interest even though it was what she wanted. Our adviser said that best clinical practice would have been to keep her in hospital, offer her pain-killing medication and establish whether a stone was present as a possible cause of her pain. We noted that at the time of her discharge she had been well and the medication she was given was appropriate. However, Mrs B's medical notes were not clear about what was discussed with her before surgery and the risk (given her previous history) was not clear. We upheld the complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• make a formal apology to Mr A;
• ensure that the consultant urologist involved in Mrs B's surgery is made aware of the outcome of this complaint and that it is discussed at their next formal appraisal; and
• confirm to us that they are satisfied that consent forms and other clinical notes contain an appropriate level of detail.