Decision Report 201609404

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received when she was a patient in the geriatric long stay facility at Mearnskirk House. Mrs A became unwell and was treated for a presumed urinary tract infection. Her condition deteriorated and she developed sepsis (blood infection) and jaundice (a condition with yellowing of the skin or whites of the eyes), and later died.

Mrs C suspected that Mrs A's urinary tract infection was from a liver source and raised concerns about the board's response to Mrs A's jaundice. However, the board considered that a urine source was more likely and that the treatment Mrs  A received had been reasonable.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the source of infection often remains uncertain in particular situations, and that treating the sepsis would be the correct priority. We considered that more vigorous medical investigations or interventions would have been disproportionate. We did not uphold Mrs C's complaint.

However, we noted that there was insufficient documentation to demonstrate adequate discussions with Mrs C regarding Mrs A's management plan, particularly surrounding the uncertainty of her recovery. We also highlighted that adequate internal communication was not demonstrated and that communication failings were contrary to Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the care of deteriorating patients. We made recommendations relating to these observations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure of clinical staff to communicate adequately, both with her and with each other. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• As per SIGN 139, patients identified as deteriorating with limited reversibility should have a written management plan which considers and includes discussion with the patient and family (which may include discussion of uncertain recovery and medical plan, preferred place of care and concerns or wishes); and standardised and agreed ceilings of care.
• As per SIGN 139, all communication about patients identified as deteriorating should be formalised and should include a structured handover process which includes all relevant clinical information.