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Case ref:201901903
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Date:July 2020
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Body:Lothian NHS Board - Acute Division
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C complained about the care and treatment she received at the Royal Infirmary of Edinburgh. Ms C complained that she was unreasonably prescribed a drug, uniphyllin, in order to treat her asthma.
We took independent advice from a consultant in respiratory and general internal medicine. We found that it was reasonable to prescribe uniphyllin for Ms C's asthma and long-term breathing difficulties. Therefore, we did not uphold this aspect of the complaint.
Ms C experienced a tonic-clonic seizure (type of seizure that involves both stiffening and twitching or jerking of a person's muscles) whilst taking the drug and said that she was not advised that this was a possible side effect. We considered that it would have been reasonable for Ms C to have been provided with information so that she could be involved in decisions made about her care and the possible side effects of medication. We upheld this aspect of Ms C's complaint.
Ms C also complained that she was given an increased dose of the drug without the effect of this being monitored. We found that the symptoms Ms C was experiencing were not necessarily a sign that the dose she was given was too high. An increase was also reasonable for maximum therapeutic effect. We did not uphold this aspect of Ms C's complaint.
Finally, Ms C complained that there was an unreasonable delay in advising her to stop taking the drug after she had a seizure. We considered that it would have been reasonable for Ms C to have been advised in A&E to stop taking the drug when she was admitted after her seizure. We upheld this aspect of Ms C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Ms C for failing to advise her of the possible side effects of the drug and for failing to advise her when she attended A&E with a seizure that she should stop taking the drug because she was at risk of further seizures. 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:
- To ensure General Medical Council good practice is followed when considering treatments to ensure patients are aware of significant side effects.
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.