Decision Report 201507465

Summary

Miss C's mother (Mrs A) was diagnosed with diverticular disease (disease of the colon) a number of years ago, but did not experience any symptoms from this and was not on medication.

Mrs A was admitted to Monklands Hospital with symptoms of abdominal pain, vomiting and weight loss and was treated for a urinary tract infection. A possible diagnosis of diverticulitis (a condition related to diverticular disease, where the abnormalities in the large intestine become inflamed or infected) was made but she was discharged for follow-up as an out-patient.

Mrs A was then admitted to Hairmyres Hospital a few days later and diagnosed with diverticulitis. Staff had planned to treat her conservatively (without surgery) for a few days, but to consider surgery if she did not improve. Mrs A suffered a heart attack during this time, and the cardiac team advised that surgery should be avoided if possible. While Mrs A initially improved, her health then deteriorated and became critical due to septicaemia (blood poisoning). Emergency surgery was carried out, but Mrs A passed away a few hours after the surgery.

Miss C complained about Mrs A's discharge from Monklands Hospital and the delay in offering surgery. She also raised concerns about nursing care, including pain management. The board met with Miss C and her family and apologised for some aspects of Mrs A's care. They also conducted a Significant Adverse Event Review (SAER) which identified a number of failings in care, including pain management and record-keeping, as well as a delay in carrying out the emergency surgery. However, Miss C was not satisfied with this response and she brought her complaint to us.

After taking independent medical and nursing advice, we upheld most of Miss C's complaints. We found the discharge from Monklands Hospital was unreasonable in view of Mrs A's condition and, while it was appropriate not to offer Mrs A surgery until her condition deteriorated (in view of the risks), we found the delay in arranging emergency surgery at this point was not reasonable. We also found failings in communication and nursing care at Hairmyres Hospital, particularly in relation to pain management and appropriate use of the MEWS (Modified Early Warning System) - although we noted that the board had taken some action to address these issues as a result of the SAER.

Recommendations

We recommended that the board:

• feed back our findings about the inappropriate discharge of Mrs A from Monklands Hospital to the staff involved for reflection and learning;
• review their process for auditing that the MEWS is being used appropriately, including escalation where appropriate to a more senior practitioner when patients deteriorate;
• apologise to Miss C for the failings identified in our investigation; and
• feed back our findings to the medical and nursing staff involved at Hairmyres Hospital for reflection and learning.