Decision Report 201701730

Summary

Mr C complained that the board failed to carry out a Significant Clinical Incident (SCI) investigation reasonably. Mr C's late partner (Ms A) underwent a hernia repair operation (an operation to correct a hernia, which is a bulging of internal organs or tissues through the wall that contains them) at a private hospital and later found this surgery had perforated her bowel. This perforation was successfully repaired with further surgery at Glasgow Royal Infirmary, however, Ms A continued to deteriorate and died shortly afterwards. The board carried out a SCI investigation which highlighted a number of failings in Ms A's care and several recommendations were made to improve practice going forwards. Mr C was unhappy with this report and complained to the board. Mr C remained unhappy with their response and brought his complaint to us.

We took independent advice from a consultant surgeon. We found that the scope of the SCI investigation was reasonable and that it had identified many of the issues with Ms A's care. However, there were some areas where the recommendations either did not address, or did not fully address, the failings. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the SCI process did not fully address all the failings in care and treatment provided to Ms A. 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:

• Emergency transfers from a hospital with no facility to manage full emergency assessment/emergency surgery to a hospital where optimal care can be provided, should be regarded as 'blue light', especially in the presence of sepsis.
• Surgical admissions of this type should be discussed with a more senior clinician (senior trainee or higher) to ensure management and treatments are optimised.
• All emergency cases should be assessed for sepsis on the Sepsis Six pathway and prompt management plans be put in place as necessary, including prompt administration of antibiotics.
• There should be standardisation of communication using an appropriate tool such as SBAR (Situation, Background, Assessment, Recommendation).