Summary
Mrs C complained that her late husband (Mr A) was not provided with appropriate care and treatment after he was admitted to Dumfries and Galloway Royal Infirmary. Mr A was admitted with a suspected stroke but developed severe diarrhoea. His condition deteriorated significantly over the next few days and he developed a number of other symptoms, including problems with his oxygen levels, his heart and his breathing. He was transferred to intensive care, but died some four weeks after he was admitted. Mrs C said that although she was very concerned about her husband's condition, he was not seen by a consultant until about a week after he was admitted. She repeatedly raised her concerns with staff, but felt these were dismissed. Mrs C felt it took too long to recognise that Mr A had had a heart attack, and said he lost all his dignity while in hospital and suffered unnecessarily.
The board met with Mrs C some months after she first complained, and wrote two months after that to further clarify what had been said, acknowledging her concerns that the heart attack was not diagnosed sooner. They said, however, that they hoped she was reassured that they had carried out a series of appropriate tests to diagnose Mr A's condition, although with hindsight this could have been done more quickly. They apologised for Mrs C's experience.
The records did not show what was said at the meeting, but there were statements from two doctors within the complaints papers. Both acknowledged that it was unfortunate that Mr A was not reviewed earlier, and that there were issues with availability of consultants. I also took independent advice on the complaint from a consultant cardiologist, who said that Mr A died following a critical illness, which culminated in multi-organ failure. Although he already had underlying health conditions, there was evidence of a recent heart attack and a related life-threatening condition. My adviser identified a number of failings in Mr A's clinical care, including that the heart attack could have been diagnosed sooner, fluid therapy was not appropriately managed, and medical records were inadequate, with electrocardiogram (heart function monitor) results that were not properly labelled and that did not appear to have been compared in sequence. This meant that Mr A was not adequately reviewed and his heart problems not considered early enough - critical omissions when planning his treatment.
I accepted this advice and upheld Mrs C's complaint. I found that Mr A was not reviewed by a cardiac consultant early enough, and was placed on inappropriate fluid therapy, which compromised his treatment and meant that his care fell below a reasonable standard. I also found the board's complaints handling and apology inadequate, given that two senior members of board staff identified failures in Mr A's care, and that I saw no evidence of the board taking action to improve procedures as a result of Mrs C's complaint.
Redress and recommendations
I recommended that the Board:
- (i) carry out a critical incident review into Mr A's death;
- (ii) remind all staff of the importance of contemporaneous, accurate and full medical notes;
- (iii) provide evidence that the complaint investigation has been reviewed, to establish why failings by the Board identified by staff members were not acted upon;
- (iv) remind all staff of the importance of discussing completion of the decision to designate a patient as 'not for resuscitation' with either the patient or appropriate family members;
- (v) provide evidence that the full report has been discussed by the Board at the first meeting following its publication; and
- (vi) apologise unreservedly to Mrs C for the failings identified in this report.