Decision Report 201904677

Summary

C complained on behalf of their spouse (A). A was admitted to University Hospital Wishaw (the hospital) with severe pancreatitis (inflammation of the pancreas). At that time, this was attributed to recent alcohol intake. They developed multi-organ dysfunction (respiratory, cardiovascular and renal) over the ensuing 24 hours, but subsequently made a slow but full recovery.

Three years later, A developed abdominal pain whilst on holiday abroad. They were again diagnosed with severe necrotic pancreatitis, which was attributed to raised triglycerides (a fatty substance similar to bad cholesterol), rather than alcohol. It was subsequently documented that they had not drunk alcohol since the earlier episode of pancreatitis. They were admitted to an intensive care unit, intubated and ventilated and managed with conservative supportive therapy. An ultrasound scan during this admission did not show that they had any gallstones. Once A was sufficiently well to travel, they were transferred to the hospital, where they remained until discharge.

A subsequently had an ultrasound and this demonstrated a thickened gallbladder containing sludge. They then underwent cholecystectomy (gallbladder removal).

C complained on behalf of A that the board unreasonably delayed in performing a test to establish the cause of A's pancreatitis. We found that the board failed to follow national guidelines by not performing ultrasound scanning at the time of A's first admission to hospital with acute pancreatitis. Ultrasound scanning might have resulted in the identification of biliary sludge within the gallbladder at that time and prompted gallbladder removal, thus potentially avoiding the more severe episode of recurrent acute pancreatitis. It should also be stressed, however, that a negative scan at that time would have been unlikely to change A's subsequent clinical course. There was little documentation of discussions with A and their family. In view of these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to perform ultrasound scanning during A's first admission to hospital and the lack of documentation of discussions with A and their family in relation to the cause of the pancreatitis. 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:

• In cases where the cause of an illness or disease is unclear, or where a diagnosis potentially confers a degree of stigma to the patient, tactful discussions should take place between the medical team and the patient and their relatives with such a discussion being carefully documented afterwards.
• Patients presenting with acute pancreatitis should undergo ultrasound scanning during their admission in order to consider gallstones as the potential cause.

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.