Decision Report 201904518

Summary

C complained about the care and treatment that they received from the board when they were admitted to Hairmyres Hospital with a psychotic episode. C raised a number of issues, including that the nursing and clinical staff at the hospital failed to adequately explore the possible link between the unpleasant/harmful physical symptoms C was experiencing, which they said they reported on a daily basis, and the medication they were given.

We took independent advice from a mental health nurse and a consultant psychiatrist. We found that, generally speaking, staff responded appropriately to C's complaints; observations, examinations, investigations and onward referrals were appropriately initiated when C voiced concerns. However, there was a clear failure to carry out daily monitoring of C's pulse and blood pressure in a consistent and reasonable manner, and record the readings and C's resulting National Early Warning System (NEWS, a pro forma for recording patients' physical observations that generates a score to alert staff to potential changes in a patient's physical condition) score on the NEWS chart. We noted that the failings in recording of C's pulse and blood pressure on the NEWS chart and the resulting NEWS score was a potential contributory factor to C developing hypotension (low blood pressure). Interventions to manage this, such as the withdrawal of Olanzapine (an antipsychotic drug), were delayed at a time when this would have been beneficial in alerting the clinical team to physical issues experienced by C. This resulted in C experiencing short term discomfort and distress from hypotension. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to consistently monitor C's pulse and blood pressure and record these, along with C's NEWS score, on the NEWS chart. 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' vital signs observations should be conducted in line with agreed frequency and the readings and resulting NEWS scores recorded on the NEWS charts.

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.