Decision Report 201701801

Summary

Mr C complained that staff failed to communicate properly with him when he arrived at Hairmyres Hospital following his wife (Mrs A)'s admission with a suspected stroke. Mr C had told the paramedics who called at his home that he thought the time of onset for the stroke was about 02:00, when he heard Mrs A collapse. When he was with Mrs A in the emergency department, and subsequently on admission to a ward, no members of staff asked him for more information which may have narrowed the potential timing of the stroke. Mr C subsequently learned that thrombolysis treatment (medication to dissolve blood clots), which can limit the damage caused by a stroke, was available but has to be given within a certain timescale to be effective. Mrs A was not given thrombolysis treatment as the clinicians had deemed that there was insufficient information available which would have identified the potential time of onset of the stroke.

We took independent advice from an adviser in acute medicine. We found that, although the staff had taken into account the information provided to the paramedics, they missed the opportunity to question Mr C further as he may have been able to provide information which would have narrowed down the potential timings. The staff took the decision not to provide thrombolysis treatment without speaking to Mr C. We noted that even if they had obtained further information from Mr C it was possible that they may still have decided not to start the thrombolysis treatment. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate with him. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should consider all available sources of information available before deciding whether or not to commence thrombolysis treatment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.