Decision Report 201911923

Summary

C complained on behalf of their sibling (A) after A was admitted to hospital with a history of progressive vomiting and nausea. The dietetics team (specialists in the scientific study of the food that people eat and its effects on health) asked for A to be prescribed thiamine (vitamin B1) for malnutrition as A had recently lost ten percent of their body weight. The prescription was not made and A did not receive the thiamine supplements. A was discharged several days later as their symptoms had improved and investigations had been generally reassuring. Several weeks later, A suffered a collapse and was readmitted to hospital with confusion and reduced mobility. After extensive investigations, A was diagnosed with Wernicke's encephalopathy (a condition which affects the brain, caused by lack of thiamine). C complained that the board had failed to provide reasonable care and treatment to A in relation to the failure to prescribe thiamine, and that discharging A had been unreasonable.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We noted that the board had previously acknowledged that there was a failure to give A thiamine when originally recommended by the dietetic team, and they had apologised for this. They had also implemented a ward round checklist to prevent similar failings recurring. However, based on the advice we received, we were concerned that the board had not fully considered or accepted the potential impact of this failure, as we considered that thiamine supplements may have at the very least lessened the severity of the Wernicke's that subsequently developed. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide A with thiamine, and for failing to acknowledge the potential impact of this. 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 potential impact of thiamine deficiency and the manner in which Wernicke's encephalopathy develops.

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.