Decision Report 201909981

Summary

C complained about the care and treatment provided to their late parent (A) in A&E. We took independent advice from an accident and emergency adviser. We found that A waited an unreasonable amount of time for a clinical review on their attendance to A&E and this did not meet the triage category standards assigned to A. We also found that sepsis (blood infection) should have been considered at an earlier stage during one of A's attendances to A&E given their low blood pressure and increased respiratory rate. We upheld this aspect of C's complaint.

C complained that the board failed to provide A with reasonable care and treatment regarding a chyle leak (an accumulation of lymphatic fluid in the abdominal cavity). We took independent advice from a surgical adviser. We found that A was provided with reasonable care and treatment for the chyle leak, that their pain and discomfort was appropriately investigated and responded to and that reasonable action was taken in relation to the prevention of blood clots. As such, we did not uphold this aspect of C's complaint.

Finally, C complained that A's mobility was not fully investigated while they were in hospital. We took independent advice from a physiotherapy adviser (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise). We found that A was provided with reasonable care by physiotherapists in the assessment and management of their mobility. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not considering sepsis at an earlier stage during A's attendance to A&E given their low blood pressure and increased respiratory rate. 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:

• Patients should receive a clinical review within triage category timescale.
• Sepsis should be considered in A&E patients who present with low blood pressure and increased respiratory rate.

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.