Decision Report 201301433

Summary

Mrs C was unhappy with the care and treatment provided to her late mother (Mrs A) when she was admitted to Glasgow Royal Infirmary to repair her broken hip. She complained about failure to manage Mrs A's diabetes, poor wound management, and failure to take appropriate action when Mrs A's condition deteriorated. Mrs A had fallen at home, and had surgery to repair her hip the following day. She developed an infection and had two more surgical procedures, including removal of a hip implant that had been inserted during the first operation. Her condition deteriorated, however, and just over a month after going into hospital she was admitted to the intensive care unit (ICU) where she died three days later.

Our investigation included taking independent advice from two of our medical advisers, a consultant orthopaedic surgeon and a consultant in critical care. We found that Mrs A's condition had been appropriately monitored and managed with specialist advice being taken from the diabetic and ICU teams when necessary. Mrs A's diabetes was known to be unstable before she went into hospital and it was difficult to control while she was there. The advisers said that this would have made her prone to infection, and that in turn, infection could have made her diabetes more difficult to control. They were satisfied that appropriate action was taken to monitor and address this, including asking the diabetes specialist nurse and a specialist registrar to review Mrs A several times.

The advisers were satisfied that the care and treatment of Mrs A's wound infection was reasonable. There were no clear indications of infection until almost two weeks after the operation and until then appropriate action was taken to investigate and address the symptoms that Mrs A was displaying. When her condition deteriorated further, the advisers said that Mrs A was appropriately reviewed by the ICU team and then transferred to the ICU. Our investigation found that, overall, the care and treatment provided to Mrs A was reasonable, appropriate, timely and in line with standard practice and national guidance.