Decision Report 201404954

Summary

Mrs C's late husband (Mr A) was admitted to Glasgow Royal Infirmary with numerous fractures following a fall. After eight days in hospital, his condition deteriorated and he died of a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Mrs C raised concerns about the orthopaedic, medical and nursing care and treatment provided saying that Mr A had not been given the best opportunity to survive given the failures in care.

We took independent advice from several medical advisers and a nursing adviser. We found that the treatment decisions to reduce the risk of pulmonary embolism were reasonable and that the risks of a pulmonary embolism could not be eliminated completely. Having said that, there was a missed opportunity for a more senior specialised medical review during this period as Mr A's National Early Warning Score (NEWS), a guide used to determine the degree of illness of a patient, was at a level that should have triggered an escalation of clinical care. We also found that there was poor record-keeping, and these failings resulted in unnecessary distress to Mrs C and her husband. In relation to nursing care, we also found record-keeping failings and a failure to alert medical staff of Mr A's deterioration during this period. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• ensure record-keeping by medical staff complies with relevant guidance;
• bring our findings to the attention of relevant medical staff;
• take steps to ensure healthcare professionals comply with the NEWS guidelines or clearly set out the rationale in patients' clinical records for non-compliance;
• ensure record-keeping by nursing staff complies with relevant guidance;
• bring our findings to the attention of relevant nursing staff; and
• apologise for the failings identified.