Overview
This complaint was brought by the Citizens' Advice Bureau (CAB), acting on behalf of the complainant (Mrs C). Mrs C complained about the standard of care her late son (Mr A) received at the Victoria Infirmary, Glasgow in the area of Greater Glasgow and Clyde NHS Board (the Board). Mr A, a young man aged 27, had been admitted on 9 May 2007, following a referral from his GP, with various symptoms including urinary incontinence, a sore throat, a cough, shortness of breath and facial swelling. He had been dizzy for two days and had had diarrhoea and faecal incontinence the night before admission. He was discharged the following day and died suddenly four days later, alone, at home. The post mortem examination revealed heart muscle disease and evidence of heart failure and it is likely that Mr A died of a sudden irregularity of the speed or rhythm of the heart.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the standard of care Mr A received fell beneath the level expected of medical practitioners (upheld); and
- (b) the Board's responses to the complainant, when Mrs C sought an explanation for Mr A's death, were poor (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise directly to Mrs C for the serious failings identified in this report;
- (ii) reflect on the medical lessons to be learned from this case and consider appropriate action;
- (iii) produce an action plan, to include education and training, to address the equality, diversity and person-centred care failings identified in this report;
- (iv) apologise to Mrs C and the CAB for the shortcomings identified in this report in their correspondence with them;
- (v) reflect on their handling and investigation of complaints involving the sudden, unexpected death of a patient; and
- (vi) reflect on their handling and investigation of complaints where the family has involved an advocacy organisation such as Action Against Medical Accidents.
The Board have accepted the recommendations and will act on them accordingly.