Decision Report 201701142

Summary

Mrs C complained about the care and treatment she received at Wishaw General Hospital. Following a heart attack, Mrs C attended the hospital on a number of occasions in the period whilst she waited for heart surgery. She was unhappy with the way the board managed her condition in this period and the way the board coordinated her care.

We took independent advice from an emergency medicine consultant, an acute physician and a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels).

Mrs C firstly raised concern that the board failed to investigate her symptoms and provide her with appropriate treatment. We found that, during the first admission, Mrs C was diagnosed with an acute coronary syndrome (symptoms attributed to obstruction of the coronary arteries). Mrs C also had hyperglycaemia (high blood glucose) but was not prescribed insulin. The adviser noted that tight blood glucose control is important in acute coronary syndrome and considered that the board failed to monitor Mrs C's blood glucose levels appropriately and failed to prescribe insulin. We also concluded that there had been a delay in Mrs C being reviewed by a cardiologist and that a GRACE score (which takes into account a patient's age, heart rate, systolic blood pressure, kidney function, signs of heart failure, as well as other parameters in order to calculate the risk of in hospital death) should have been calculated earlier as this can inform the need for angiography (a type of x-ray used to check the blood vessels). In relation to a later hospital admission, we considered that it was unreasonable for the board to have discharged Mrs C without assessment by a senior physician, in view of her medical history and presenting symptoms. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to coordinate her surgery with another NHS organisation that was involved in her care. The board acknowledged that there was a lack of detail in the documentation of the conversation between their medical staff and the staff from the other organisation. We found a number of points in Mrs C's care where the communication with the other organisation could have been better. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to investigate her complaint reasonably. The board acknowledged that they had not addressed all the issues raised in her complaint letter. We considered that since Mrs C's original complaint spanned two NHS organisations, and the co-ordination and communication involved between each, the board should have worked more closely with the other organisation and issued a single complaint response. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable care and treatment; unreasonably discharging her without assessment by a senior physician; failing to coordinate her care with another board reasonably; and not fully responding to her complaint. 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:

• Where a patient presents with an acute coronary syndrome and has hyperglycaemia, close monitoring of blood glucose levels should be a routine part of acute coronary syndrome management. Insulin should be prescribed for patients who require insulin and adm
• Patients who have been diagnosed with an acute coronary syndrome should be reviewed by a cardiologist within a reasonable timescale. In line with guidelines, patients should be risk assessed for future adverse cardiovascular events and the timing of coron

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