Decision Report 201508619

Summary

Mrs C complained to us about the medical care and treatment provided to her late father (Mr A) at the Western General Hospital before his death. Mr A had previously been diagnosed with rheumatoid arthritis associated interstitial lung disease (a group of disorders characterized by inflammation and scarring of the lung tissue). He was admitted to hospital and a CT scan showed that he had inflammation and a possible infection in his chest. He was given steroids and antibiotics to treat this and was then discharged. Mr A was then admitted to hospital again with increased breathlessness. He was again treated with antibiotics and discharged after physiotherapy. Mr A was subsequently admitted to hospital again with increased shortness of breath. A chest x-ray showed that this was most likely pneumonia. His condition deteriorated in the hospital and Mr A died there several days later.

We took independent medical advice from a consultant in respiratory medicine. We found that the care and treatment provided to Mr A had been reasonable. However, when he was discharged from hospital on the second occasion it was decided that he could be reassessed for portable home oxygen at his respiratory clinic appointment which the staff thought was two or three weeks later. However, they did not check the date of the clinic appointment and it was in fact nearly six weeks after Mr A was discharged. We found that this was too long to wait to assess Mr A and for this reason we upheld this aspect of Mrs C's complaint.

Mrs C also complained about the nursing care Mr A received. We took independent nursing advice. We found that there had been a number of failings but we were satisfied that the board had apologised and had taken action to try to prevent similar problems recurring.

In addition, Mrs C complained about the communication with Mr A and her family. We found that this had been inadequate and upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• confirm that relevant staff are now working in line with the NHS quality standard on assessment for oxygen therapy.