Overview
The complainant (Mrs C) raised a number of concerns with Lanarkshire NHS Board (the Board) concerning the care and treatment her father (Mr A) received for a gangrenous toe between 4 January and 12 March 2011 while a patient in three different hospitals, including Monklands General Hospital (Hospital 1), Hairmyres Hospital (Hospital 2) and Wester Moffat Hospital (Hospital 3). Mr A died from sepsis (a bacterial infection in the bloodstream) on 12 March 2011.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the treatment provided to Mr A for his gangrenous toe was inadequate and failed to address the infection and prevent him contracting sepsis (upheld);
- (b) during Mr A's admissions to the three hospitals, staff unreasonably failed to recognise, monitor and address his pain, agitation and confusion (upheld);
- (c) between 9 and 10 March 2011 Mr A's medication was inappropriately changed causing him to become very distressed and unresponsive (upheld);
- (d) there was an unreasonable delay in transferring Mr A to Hospital 1 on 12 March 2011 when his condition had deteriorated (upheld); and
- (e) during Mr A's hospital admissions from 4 January to 12 March 2011, the family constantly raised their concerns about Mr A's deteriorating condition but these were unreasonably ignored (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensures that Doctor 1 reflects in his annual appraisal on Adviser 1's comments in terms of the lack of evidence in the medical records to show that all surgical options were considered and discussed with Mr A and the family where relevant;
- (ii) review the application of the MEWS chart in Hospital 3 to ensure that staff can readily identify patients who have deteriorated and require urgent attention;
- (iii) conduct a significant event analysis with regards to Mr A's transfer from Hospital 3 to Hospital 1, to ensure that in future patients who are significantly unwell and deteriorating are transferred in a timely manner. This should also take into account Mr A's pain management at Hospital 3; and
- (iv) apologise to Mrs C and the family for the failings identified in this report.