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Case ref:202003095
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Date:February 2022
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Body:Tayside NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:Clinical treatment / diagnosis
Summary
C's child (A) had complex needs as a result of a brain injury sustained when they were four years old. Given A's care needs, they had an Anticipatory Care Plan (ACP) in place which was reviewed regularly.
A was admitted to a general ward at Ninewells Hospital with a high temperature and was subsequently moved to a high dependency unit. A died three days following admission.
C complained about the inappropriate use of Hi-Flo Nasal Cannula Oxygen (high-flow oxygen, a form of respiratory support) despite concerns raised at the time. C complained that incorrect decisions were taken with respect to A's care and treatment, including that clinicians did not have appropriate regard to the ACP that was in place.
In response to the complaint, the health board carried out a Mortality Review and shared its findings with C. The findings were that care was maximised in the High Dependency Unit as it was not felt A would survive admission to Paediatric Intensive Care Unit, and that this decision together with the decision not to intubate was made with C's input. The variation in care from the ACP was discussed with C and highlights plans are flexible.
C complained to our office that clinicians failed to follow the ACP, that they did not take their views into consideration and that A died of carbon monoxide poisoning as a result of the decisions made in relation to A's treatment and care.
We took independent advice from a consultant paediatrician. We found that there was good documentation evidencing that clinicians had discussed A's care with C, including decisions not to intubate A. We considered treatment with high-flow oxygen was reasonable in the circumstances. Whilst the ACP was not followed, and the board identified this, the ACP is not a legally binding document and the decisions to deviate from the ACP were reasonable in the circumstances. A's cause of death is consistent with the evidence within the medical records. We concluded that A's care and treatment was reasonable and did not uphold the complaint.