Decision Report 201908475

Summary

C complained to us on behalf of their adult child (A). A had several attendances at Victoria Hospital and admissions for further investigation following a period of illness with severe stomach pain, nausea and vomiting. C raised concerns about A's medical care and their nursing care.

We took independent advice from a consultant gastroenterologist (a specialist in diagnosing and treating disorders of the stomach and intestines). We found that A was given appropriate medical care and treatment and we did not uphold that aspect of C's complaint.

We also took independent advice from an acute nursing specialist. We found that there were delays or issues in getting some of A's prescribed medications. Also, on one occasion, A was given a dose of a medication that was higher than recommended. We found that as A developed a staph aureus bacteraemia (SAB, where a bacteria commonly found on the skin enters the body) infection during their admission, the board appropriately carried out a significant adverse event review and took steps to improve this aspect of care. However, we found that the specific concerns that A's family raised about what caused A's SAB infection should have been addressed in their significant adverse event review. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care. 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:

• Adverse event reviews should address questions or concerns raised by the patient/their family, in line with relevant guidance.
• Medication should be administered to patients safely, appropriately and in line with their prescription.
• The board should have an appropriate system in place for accessing and administering less common medications.

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.