Decision Report 201904890

Summary

C complained about the care and treatment provided to their parent (A). A was reviewed in the A&E department of a GP led community hospital with epigastric pain (pain or discomfort right below the ribs in the area of the upper abdomen). A felt that the pain was coming from their gallbladder. Tests for a urinary tract infection (UTI) were carried out and A was admitted to a ward for fluids and treatment with an antibiotic. A few days later, the decision was taken to transfer A to another hospital. Further tests carried out there revealed A's gallbladder had perforated causing an abscess on their liver. They were then subsequently diagnosed with gallbladder cancer.

C complained about the care and treatment provided to A at the community hospital. The board said that gallbladder pain usually radiates to the shoulder which was why this was considered unlikely in A's case. A was stable but diagnosis was unclear so they were admitted for observation and antibiotics for a UTI, which had been confirmed on testing.

We took independent advice from an appropriately qualified clinical adviser. We found that A did not have specific clinical features of a UTI and urinalysis was not convincing for a bacterial infection. The clinical presentation of nausea, sweating and epigastric pain accompanied by the finding of the right upper quadrant tenderness was more in keeping with gallbladder pain and infection. We also noted that once A's abnormal blood results were known, the decision should have been taken on that same day (the day following admission) to consider transferring A to secondary care, because their clinical condition and abnormal blood results suggested something that could not be managed properly or adequately in a GP led community hospital. We also found that A was given too much IV fluid during their admission. Given A's known history of heart failure, the administering of fluid should have been regularly reviewed. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failure to acknowledge that A did not have specific clinical features of a UTI and recognising that urinalysis did not indicate bacterial infection; failure to appropriately consider gallbladder pain and infection; administering too much IV fluid during A's admission and for not reviewing this regularly; failure to take A's abnormal blood result seriously; and failing to appropriately consider transferring A to an acute hospital once their blood results were known, given their clinical condition. 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:

• The board should implement clear guidance within the GP led community hospital to make clear who can be admitted along with clarity on the level of care that can be provided. The guidance should include criteria under which transfer to an acute hospital should be considered.
• The board should share this decision with the doctors involved in a supportive manner, and ask that they reflect on A's case.

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.