Decision Report 201901389

Summary

C's spouse (A) suffered from chronic pancreatitis (inflammation of the pancreas) and was receiving care and treatment from the board. A attended hospital multiple times over several months. A was discharged home but the following day they were admitted again with significant pain and died.

C complained to the board, raising a number of specific questions about the treatment provided to A and was of the view that more could have been done to help A.

We took independent advice from a consultant general surgeon. We found that while during the majority of A's admissions, the treatment provided by the board was reasonable, there was a significant failing in relation to A's discharge the day before their death. At the time A was discharged, their observations were still abnormal, A's pain score remained high and there was no evidence that the blood test results had been reviewed prior to discharge. We concluded that to discharge A at that time was unreasonable. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable treatment. 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:

• Ensure there is a clear policy in place on discharging patients with abnormal observations from A&E.

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.