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Case ref:201508385
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Date:September 2016
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Miss C's mother (Mrs A) was admitted to Glasgow Royal Infirmary with an exacerbation of her chronic obstructive pulmonary disease (COPD – a disease of the lungs in which the airways become narrowed). Miss C complained about the care and treatment her mother received from the board whilst in hospital and the arrangements for her subsequent transport home. She was concerned that her mother was weaned off oxygen too early. She was also concerned that the board should not have considered her mother for a normal flight home when she had been admitted to hospital with a severe COPD attack and chest infection. Miss C said that her mother should have been transported home by air ambulance.
We obtained independent advice on the case from a consultant respiratory and general physician. The adviser said there was no evidence to suggest that Mrs A was weaned off oxygen too early. They explained that Mrs A needed oxygen from day one to day five of her admission but that from day six to day eight her oxygen levels were stable and at a satisfactory level and no additional oxygen was required.
In terms of Mrs A's discharge and transport home, the adviser said that as Mrs A had been assessed appropriately by the board, her condition was deemed to be stable and she had recovered from her recent COPD exacerbation. We found that, on balance, it was reasonable for her to have been discharged and flown home on a short, low altitude, commercial flight without provision of additional oxygen.
Although we concluded that Mrs A received reasonable medical care during her in-patient stay and that her discharge arrangements were appropriate, we were concerned about the standard of the handwriting in Mrs A's medical records, the standard of the photocopy supplied to this office, the board's handling of Miss C's complaint and the board's late submission of their comments on this case to our office. We therefore made some recommendations to address these issues.
Recommendations
We recommended that the board:
- feed back the failings identified in our decision on Miss C's complaint to the staff involved;
- ensure that in future readings are clearly recorded in patient records; and
- provide Miss C with a written apology for the failings identified.