Decision Report 201706358

Summary

Ms C, who works for an advice and support agency, complained on behalf of Mr B about the care and treatment provided to his late wife (Mrs A) at Queen Elizabeth University Hospital. Ms C raised concerns about the medical and nursing care and treatment provided to Mrs A, about the decision to transfer Mrs A to another hospital, and that Mrs A's family were not advised of the transfer.

We took independent advice from a consultant physician/geriatrician (a medical doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the medical treatment provided to Mrs A was reasonable, and did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst many aspects were reasonable, there was a failure to swab Mrs A's leg ulcers on admission to the hospital and this was a breach of the board's standard operating procedure on

meticillin-resistant Staphylococcus aureus (MRSA - a type of bacteria that is resistant to several widely used antibiotics). Mrs A's leg ulcers were found to be MRSA positive when she transferred to another hospital. We upheld this aspect of Ms C's complaint. However, we were unable to conclude if this could have been avoided if Mrs A had been swabbed on admission.

We found that the decision to transfer Mrs A to another hospital was unreasonable given Mrs A's condition and we upheld this aspect of Ms C's complaint. However we found that her family were appropriately advised of this and did not uphold the complaint about communication of the transfer.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to swab Mrs A's leg ulcers for MRSA on admission and unreasonably transferring Mrs A to a different hospital. 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:

• The multidisciplinary team should satisfy themselves that a patient is suitable and fit before being transferred.
• Staff should follow the board's MRSA Standard Operating Procedure.