Decision Report 202003058

Summary

C complained about an admission to Forth Valley Royal Hospital two weeks after undergoing emergency bowel surgery there. C was admitted with a fever and vomiting and spent many hours on a trolley in A&E in severe pain. They were diagnosed with an abdominal abscess (a painful swelling caused by a build-up of pus). C complained that the abscess was drained by a surgeon while they were still on the trolley in unsterile conditions and with no anaesthetic. C complained that they were left with the wound open and that they did not receive antibiotics until later that evening, after they were transferred to the Surgical Assessment Unit. C complained that they were left with a soaked dressing and a foul-smelling wound until the following morning. They complained that failings in their care and treatment led to development of an MRSA infection (a bacterial infection that is resistant to a number of widely used antibiotics) and a hernia at the wound site.

We took independent advice from a consultant in emergency medicine. While acknowledging the length of time C had to wait for a bed, we found that generally C’s care and treatment were reasonable. We found that C was assessed appropriately and received reasonable treatment for their condition within an acceptable timescale. However, we noted that there had been a delay in C receiving antibiotics which was unreasonable. Whilst recognising how difficult C’s experience had been, on balance, we did not uphold the complaint about the standard of care and treatment in A&E.

We also took independent advice from a general surgeon. We found that C had generally been treated appropriately and that the development of MRSA and a hernia had not occurred as a result of any failings in care and treatment. Despite there being no significant clinical failings, we acknowledged C’s extremely poor patient experience including the board’s apparent failure to ensure that C was kept clean with their wound dressing changed in a timely manner. On balance, we upheld the complaint about the standard of care and treatment in the Surgical Assessment Unit.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in providing an adequate wash and changing of their dressing, with recognition of the impact these matters have had on them. 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 ensure that patients are kept adequately clean and dressings changed when needed.

In relation to complaints handling, we recommended:

• Complaints are responded to as comprehensively as possible, particularly in situations in which complainants have requested that specific matters are investigated.

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.