Decision Report 201500441

Summary

Mrs C's mother (Mrs A) was admitted to the Glasgow Royal Infirmary with a chest infection. After initial improvement and transfer to another ward her condition deteriorated. She suffered a cardiac arrest and died while awaiting admittance to the intensive care unit. Mrs C raised a number of concerns about her mother's care and treatment. These included that the board's medical and nursing staff failed to review, monitor and treat her mother appropriately and that the board did not make reasonable efforts to communicate her mother's condition to her family.

We obtained independent advice on the complaint from a consultant physician and a nurse. The consultant adviser explained that Mrs A was reviewed by medical staff on several occasions each day, including specialist haematology input. They said Mrs A's treatment included antibiotics which were reviewed and altered according to her evolving clinical problems and results from the laboratory. The consultant adviser said all of this was reasonable.

The nursing adviser said that observations on Mrs A were carried out frequently and in accordance with the board's policy. They said that when Mrs A's condition deteriorated, the appropriate action was taken with the nursing staff reporting this to a senior clinician.

From Mrs A's arrival on the hospital ward to the point when her health deteriorated, the advisers were not critical of the level of communication with the family. However, the advisers considered that after Mrs C and her family were called to attend hospital following the deterioration in Mrs A's health, the board did not make reasonable efforts to communicate with Mrs C and her family about Mrs A's condition. We upheld this aspect of Mrs C's complaint and made a recommendation to the board.

Recommendations

We recommended that the board:

• provide us with evidence of the steps that have been taken to ensure that in future proactive communication takes place with a patient's family when a patient deteriorates.