Decision Report 201805512

Summary

Mrs C complained about the care and treatment which her late brother (Mr A) received at Aberdeen Royal Infirmary. Mr A died suddenly at home, two days after being discharged from hospital. The cause of death was recorded as colonic impaction (hard stool in the colon) and renal failure (kidney failure). Mr A had been admitted to hospital as an emergency with colonic impaction and problems with urination. A manual evacuation of the bowel was carried out under anaesthetic along with trials of catheterisation (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Mr A was discharged with a catheter in situation and arrangements made for a urology review as an out-patient. Mrs C believed that Mr A had received inadequate care in hospital.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that while in hospital Mr A did undergo a number of appropriate investigations such as blood tests; radiographs of the abdomen and chest; bladder scan; suppositories; manual evacuation of the bowel under anaesthetic; and catheterisation. However, on the day of discharge there were signs that Mr A was still unable to manage a normal bowel motion and his urine output was low compared to his normal urine output levels. We found that staff should have arranged a urology review in hospital prior to discharge rather than refer for an out-patient appointment in due course. We also found that arrangements should have been made for urgent review of Mr A's inability to manage a normal bowel motion in the days after discharge from hospital. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to establish the reasons for Mr A's urine retention and to ensure that he had normal bowel movement prior to discharge. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should ensure that, where appropriate, an assessment has been carried out into the patient's ability to pass urine and maintain normal bowel motion prior to discharge.