Decision Report 201900137

Summary

Mrs C complained about the treatment which her late husband (Mr A) received at the Queen Elizabeth University Hospital following a fall, in which he sustained a fractured leg. Mr A was admitted for conservative treatment rather than surgery, however, a few days after admission, Mr A's condition deteriorated; he suffered a cardiac arrest and was taken to intensive care.

We took independent advice from an medical adviser. We found that initially Mr A received appropriate medical care in view of his presenting symptoms, but when Mr A's condition began to deteriorate, there was an avoidable delay by junior medical staff in seeking a more senior medical review for Mr A. While this may not have prevented the cardiac arrest or affected the final outcome, it would have allowed for the appropriate medical investigations to be instigated at an earlier time. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to refer Mr A for a senior medical review at an earlier stage. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Staff should be aware of the need to refer patients for a more senior medical review when their medical condition deteriorates.

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.