Decision Report 201304716

Summary

Mrs C complained on behalf of her late mother (Mrs A) about the care and treatment Mrs A received at Monklands Hospital. She had fractured her neck and was admitted to hospital for conservative management (medical treatment avoiding radical therapeutic measures or operations).

Mrs A had a history of chronic obstructive pulmonary disease (a type of lung disease) and was treated for a chest infection whilst in hospital. She was also found to have fractured ribs. Mrs A's chest condition deteriorated and an x-ray revealed a haemothorax (blood in the cavity surrounding the lung). A chest drain was inserted to drain the fluid, and she was transferred to the High Dependency Unit for several days then transferred back to the ward when her condition stabilised. However, a few days later she suffered a rapid deterioration and died.

We took independent advice on this case from one of our medical advisers who found that the decision to transfer Mrs A back to the ward was reasonable given that her breathing rate, oxygen levels, blood pressure, and heart rate were all stable and met the board's transfer criteria in this respect. We also took independent advice from our nursing adviser, and noted that the board had acknowledged that there was delay in a drip being reconnected due to the cannula (intravenous tube) becoming dislodged and that a dose of antibiotics was missed. They provided refresher training for the ward staff, and a member of the nursing staff had apologised to the family. We found this reasonable and our nursing adviser considered that this was not a significant failing that affected the overall outcome for Mrs A.

Although we noted that the board had arranged for staff to have refresher training in relation to chest drains, neither of our advisers identified any evidence of failings with the management of the chest drain. In relation to Mrs C's concerns about staffing on the ward, we found that some of the shifts had lower numbers than planned, but that bank staff and overtime were used to address this, which was reasonable. On balance, we concluded that the medical and nursing care was reasonable.