Decision Report 201908034

Summary

C complained about the care and treatment of their late parent (A) in the weeks prior to their death in Queen Margaret Hospital. C raised concerns that staff failed to notice and act upon A's deteriorating condition, and particularly a dramatic deterioration on the day that A died. C noted that the post mortem identified evidence of a chest infection, and they complained that A died of an easily treatable condition. C raised concerns about the stoppage of A's diuretic medication (drugs that enable the body to get rid of excess fluids), which they considered contributed to a fluid build-up in A's lungs.

We obtained independent medical advice from a consultant geriatrician (a doctor specialising in medical care for the elderly), who noted from the records that the expected level of observations took place. We found that sufficient attention was paid to A's fluid build-up, and that the decision to stop their diuretic medication was reasonable in the circumstances. However, we noted that A's vomiting and unstable observations in the days prior to their death were not acted upon. We noted that this should have prompted further clinical review. While we could not be certain that this would have identified a chest infection or how unwell A was, we considered that this should have received more attention from medical staff. We found no evidence to support that any dramatic deterioration in A's condition was overlooked on the day A died. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to act on A's vomiting and abnormal observations in the last few days of their life. 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:

• Abnormal clinical observations (such as low blood pressure and high heart rate) and vomiting should prompt timely clinical review / further assessment of the patient.

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.