Overview
The Ombudsman received a complaint from a member of the public (Mrs C). Mrs C complained that her husband (Mr C) had not received the appropriate treatment further to a telephone call to the out-of-hours emergency medical services provided jointly between the NHS 24 and Greater Glasgow and Clyde NHS Board (the Board), during which time it is stated by the family they had been unable to get the service to accept their description of Mr C's illness. He had been out early in the evening and returned home complaining of a headache. Initially, Mr C had been advised to take medication available in the house, rest and let NHS 24 know if there was no improvement. He was admitted to the Southern General Hospital the following morning and died eight days later of subarachnoid haemorrhage. Mrs C complained that there was a delay of 12 hours without treatment for her husband.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) NHS 24 failed to provide proper care and treatment to Mr C (upheld); and
- (b) the Board failed to provide proper care and treatment to Mr C (upheld).
Redress and recommendations
The Ombudsman recommends that:
- (i) NHS 24 provide an apology to Mrs C and her family for the delay in transferring the necessary clinical details to the correct out-of-hours service;
- (ii) NHS 24 conduct an evaluation into a review of the improvements introduced by NHS 24 as a result of this complaint;
- (iii) NHS 24 ensure call handlers' basic training is developed enough to ensure staff are able to determine how to manage information they are given when a call is made from a service user, and the mechanism to transfer vital clinical information between services is reviewed to avoid mistakes in transmission arising;
- (iv) NHS 24 ensure the algorithms are fit for purpose in so far as they are able to capture the appropriate detailed information to assist the nurses to make the appropriate decisions;
- (v) the Board provide an apology to Mrs C and her family for the delay in picking up on the clinical symptoms described by Mr C and his family;
- (vi) the Board undertake a further review of the triage doctor's clinical practice in order to ensure their understanding of the signs and symptoms of a subarachnoid haemorrhage; and
- (vii) the Board ensure the triage doctor reflects on the lessons of the case, shares it with his appraiser during his next appraisal and is aware of the possibilities of rare diagnoses such as subarachnoid haemorrhage for future work.
NHS 24 and the Board have accepted the recommendations and will act on them accordingly.