Decision Report 202201594

Summary

C complained to the board about various aspects of the board’s care and treatment of their partner (A) and their communication with C and A during an inpatient admission covering the end of A’s pregnancy and the birth of their child (B) by caesarean section. The board accepted that a number of areas of communication had not been reasonable and apologised for this. The board explained what action would be taken to address these areas for improvement. The board also accepted that in a few specific cases, A had not received reasonable care but indicated that they considered A’s care and treatment had been reasonable overall. In response to a specific complaint from C, the board stated that A had not had sepsis (blood infection) or been treated for it during their admission. A few months later, however, the board wrote to C and stated that their labour had been complicated by sepsis.

We took independent advice from an appropriately qualified midwife. We found that, overall, A and B received good care and appropriate standards of treatment that were in line with relevant professional standards. Given this, and that reasonable actions to minimise recurrence were taken in relation to areas where the board had accepted care was not of an acceptable standard, and where communication could have been improved, we did not uphold the complaint that the board had not provided reasonable care and treatment to A.

We found that A had had sepsis during their admission and receive prompt and appropriate care. However, we considered that the board’s repeated altering of their position on whether A had sepsis, both minimised A’s experience and, potentially risked inadequate care and treatment responses being provided to patients with suspected sepsis in the future. We upheld the complaint that the board’s response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that their response inaccurately stated that A did not have sepsis and was not treated for sepsis during their 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:

• Relevant board staff have a clear understanding of the symptoms and diagnosis of sepsis and the actions to take in treating sepsis and suspected sepsis.

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.