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Case ref:201301243
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Date:May 2016
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Body:Lanarkshire NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained about the care and treatment of his late wife (Mrs C) during her admission to Hairmyres Hospital. Staff suspected Mrs C had a rare endocrinology (related to hormones) disease, and arranged a number of tests to investigate this over the next two months. Mrs C developed sepsis (a blood infection) while in hospital and died.
Mr C raised concerns about Mrs C's overall treatment, including delays in investigations and treatment and failure to prevent infection. Mr C was also concerned that nurses did not understand Mrs C's condition (as she was nursed on a cardiology ward, rather than an endocrinology ward). The board met with Mr C's family twice and apologised for a number of aspects of care. They arranged a meeting to ensure nursing staff reflected on their practice, and developed an action plan for improvement, which they shared with the family. The endocrinologist involved in Mrs C's care also apologised that the investigations of Mrs C's condition did not move more quickly, and explained that they expected to have more time to treat Mrs C. Mr C was not satisfied with the board's response to some parts of his complaint, and brought these to us.
After taking independent medical and nursing advice, we upheld one of Mr C's five complaints. We found the medical and nursing care was reasonable in relation to most of the specific points Mr C raised, and that although there were some failings in nursing care, the board had already addressed these. However, we found that there was an unreasonable delay in sending laboratory samples to be tested.
The medical adviser also commented on Mrs C's overall care and said the board should have considered transferring her to a larger endocrine unit (which might have resulted in quicker treatment). We shared these comments with the board, but did not make any specific recommendations as the relevant guidelines do not require treatment in a particular setting and the endocrinologist involved had already apologised to the family and reflected on their practice.
Recommendations
We recommended that the board:
- review their processes for arranging external laboratory testing of samples, to ensure this is being completed in a reasonable timeframe.