Decision Report 202005066

  • Case ref:
    202005066
  • Date:
    January 2022
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C brought a complaint about the care and treatment that their late spouse (A) received during three admissions to Aberdeen Royal Infirmary. C was concerned that A did not receive appropriate treatment and was discharged on each occasion. A was initially admitted following a heart attack, and died a few months later due to heart failure.

We took independent advice from a consultant cardiologist (medical specialist dealing with disorders of the heart). We found that the care and treatment A received during two of these admissions was reasonable, including the decision to discharge A. However, during one admission the board acknowledged that there was a missed opportunity to provide cardiology input and seek an in-patient echocardiogram (a heart scan that uses sound waves to create images).

We found that it was unreasonable that no input was sought from the cardiology department during this particular admission and that an opportunity was lost to make the correct diagnosis and to optimise possible treatment options. We upheld the complaint but also noted that it was not possible to say definitively whether this would have changed A's survival prospects.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for not seeking input from the cardiology department during A's admission. 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:

  • Input should be sought from the cardiology department where a patient has reduced cardiac function following a recent history of heart attack.

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.

Updated: January 19, 2022