Decision Report 201406738

Summary

Ms C, who is an advice worker, complained on behalf of her client, whose husband (Mr A) had died following two hospital admissions at Perth Royal Infirmary a short period apart. Mr A had suffered two strokes in quick succession. Ms C complained that he had not been diagnosed quickly enough with a stroke on his first admission. On his second admission, Ms C complained that Mr A was not provided with medical review quickly enough and that nursing staff were slow to address his obvious pain and distress. As a result, although the family accepted that his second stroke was terminal, Ms C said that they were subjected to an unnecessarily distressing and undignified experience.

We took independent advice from a nursing adviser and a medical adviser. The medical advice stated that Mr A had received the appropriate medical care on both admissions. On his first admission, he had presented with a complex combination of medical problems, including pneumonia and infection. The decision had been taken to stabilise his condition, which was reasonable in the circumstances. Our adviser said that his stroke had been diagnosed inside a reasonable time-frame. During his second admission, we found that Mr A had been provided with a medical review within the limits imposed by the responding doctor's clinical commitments. Our nursing adviser said there were shortcomings in the nursing care provided to Mr A, but that the board had recognised and apologised for these. The board had provided an action plan, which our adviser felt addressed the shortcomings identified and were able to evidence that it was being put into action.

We found that Mr A had received reasonable medical care, although his nursing care had fallen below a reasonable standard. In view of the actions already taken by the board, however, we made no recommendations.