Decision Report 201507892

Summary

Mrs C complained that one of the board's clinicians failed to provide her late daughter (Ms A) with appropriate treatment.

Ms A suffered from epilepsy and cerebral palsy. The clinician prescribed a particular medication for Ms A due to an increase in her seizures. Over the following months Ms A attended A&E at a number of points due to seizures and was seen by the board's A&E clinicians. Approximately 18 months later Ms A was taken to hospital where it was identified that she was suffering from end stage renal failure, and she later died.

Mrs C said that she raised concerns about the prescription of the particular medication to Ms A, which she linked to Ms A's death. She said the board should have further monitored Ms A. The board considered that the care and treatment had been appropriate, and said that there was no link between the medication and Ms A's deterioration.

After obtaining independent medical advice we did not uphold Mrs C's complaint concerning the board's clinician. We found that the board's clinician had followed national guidance regarding the medication and that the decision to prescribe this was reasonable in the circumstances. We found no link between this medication and Ms A's outcome.

While we did not uphold the complaint Mrs C brought to our office, we found evidence that clinicians within the board had not acted on high blood pressure readings taken from Ms A on two A&E attendances. We made a number of recommendations to the board regarding this issue.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise for failing to act on Ms A's high blood pressure readings.

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

• The board should ensure that staff are aware of guidance that recordings of high blood pressure should be acted upon.
• The board should ensure that the circumstances of this case have been fully considered for wider learning at a significant review level.

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.