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Case ref:201907414
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Date:May 2021
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Body:Dumfries and Galloway NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained about the care and treatment their late relative (A) received at Dumfries and Galloway Royal Infirmary. A reported that they did not feel well, had difficulty pronouncing words and were a little confused. A then had a fall at home before being taken to hospital.
A was treated for a chest infection but died the next morning. C raised a number of concerns regarding the care that was provided and the staff's attitude towards A and C.
We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A's initial assessment was reasonable; they were appropriately examined, their medical history taken and their existing medication noted. However, we noted that an x-ray taken to help with diagnosis showed appearances that were more consistent with heart failure than a chest infection. From the available evidence, it appeared that A was incorrectly diagnosed as having a chest infection, commenced on a suboptimal treatment pathway and left without being monitored effectively overnight. The true nature of A's condition was only identified when the consultant attended the next morning. A died shortly afterwards.
Whilst clinically the outcome may not have changed for A, had C had accurate information about their condition, they may have been better placed to support A. We considered that the care and treatment fell below a reasonable standard and upheld C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for failing to provide A with reasonable care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
In relation to complaints handling, we recommended:
- That the board share this decision with the staff responsible for A's care to ensure that any points of learning are identified and acted upon.
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.