Decision Report 201302400

Summary

Mr C complained on behalf of a relative (Ms B) about the care and treatment provided to her partner (Mr A) during two admissions to Wishaw General Hospital before his death. Mr A was first admitted after being taken there by ambulance late at night. He had a history of cirrhosis (long term liver damage) and gastric varices (dilated veins in the stomach), chronic obstructive pulmonary disease (a lung disease related to narrowed airways), type 2 diabetes and gout. It was identified that he had low blood pressure, dehydration and kidney impairment. He was treated with fluids, his medications were reviewed to try to improve his condition and tests were carried out on a potential abnormality in his bowel. Mr A was discharged from hospital after a week, as his blood tests had returned to normal, but was readmitted three days later, as he was short of breath. The admitting junior doctor noted that Mr A had increasing breathlessness and swelling of his hands and legs. Mr A initially started to improve, but five days after admission his condition deteriorated rapidly and he died three days later.

We took independent advice on Mr C's complaint from two of our advisers, a nurse and a medical adviser. We found that the care and treatment provided to Mr A during his first admission was reasonable and appropriate. He was also adequately assessed by a physiotherapist before he was discharged. Although staff did forget to remove heart monitor cables from his skin before he was discharged, the advice we received was that these were unlikely to have caused Mr A any harm.

We found that in general, the medical and nursing care and treatment provided to Mr A during his second admission was also reasonable. However, staff had noted that blood tests should be repeated the day after Mr A was admitted. There was no evidence that this was done over the next four days, although a later note in the records said that staff were unable to carry out a blood test because of difficulty in finding veins under Mr A's skin to withdraw blood. If this was the reason why blood tests were not carried out over the four days, this should have been documented at the time. We noted that, after examining Mr A's clinical records, our medical adviser explained that it was likely that Mr A's condition would have deteriorated and that he would have died even if the blood tests had been performed as planned. We did, however, uphold this aspect of Mr C's complaint in view of the failure to complete the planned blood tests or to document why these were not carried out.

Recommendations

We recommended that the board:

• issue a written apology to Ms B for the failure to carry out blood tests as planned or to document why this was not done; and
• ensure that the staff involved in Mr A's care and treatment are made aware of our findings on this matter.