Overview
The complainant (Mr C) raised a number of concerns regarding the clinical treatment that his father (Mr A) received whilst under the care of Greater Glasgow and Clyde NHS Board (the Board). He believed that staff at Glasgow’s Victoria Infirmary failed to give due consideration to Mr A’s previous medical history and that, had they done so, his death in December 2006 could have been avoided. Mr C also complained that the medication prescribed for another of Mr A’s conditions was unsuitable and that it potentially contributed to his deterioration.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board inappropriately treated Mr A with Methotrexate (not upheld);
- (b) the Board failed to take adequate note of Mr A’s past medical history when treating him (upheld);
- (c) the Board failed to proactively seek information relating to Mr A’s past medical history (upheld);
- (d) the Board inappropriately reduced Mr A’s steroid dosages before the full extent of his illness was known (upheld); and
- (e) Mr A’s death certificate did not accurately reflect the cause of death (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) formally apologise to Mr C and his family;
- (ii) remind all staff of the importance of sourcing and reviewing historical clinical records;
- (iii) review their record-keeping practices and introduce procedures to ensure the prompt identification, sourcing and provision of historical clinical records;
- (iv) considers ways to promptly source specific records relating to relevant information raised by patients and their families; and
- (v) ask the clinical team to review the circumstances of this case to see if there are any lessons that can be learned regarding the diagnosis and treatment of organising pneumonia.
The Board have accepted the recommendations and will act upon them accordingly.