Summary
Mrs A had a complex medical history, including heart problems and a low blood count. She fell ill, complaining of central chest pain, and an ambulance was called. The paramedics recommended that, due to the possibility of a heart attack, she was taken to Hairmyres Hospital because of the cardiac unit there. Mrs A was reviewed by a junior doctor in the emergency department, who diagnosed stable angina secondary to anaemia (chest pain due to the blood not carrying enough oxygen). Instead of the cardiac unit, she was transferred to Ward 2, the hospital's medical assessment unit. Within 48 hours she was transferred again to Ward 11, then moved to the high dependency unit and, finally, to a side room for palliative care (care provided solely to prevent or relieve suffering) where she died a few days later.
Mrs A's daughter (Mrs C) complained about the care and treatment Mrs A received when she was admitted to the emergency department at Hairmyres Hospital. In particular, she was concerned that staff did not check Mrs A's medical records to see what her anticoagulation level (INR - a measure of how long it takes blood to clot) should be, and that she was given a high dose of aspirin and other blood-thinning drugs, which seemed to cause major internal bleeding. She complained that Mrs A was not admitted to a cardiac ward and that she was moved from Ward 2 to Ward 11 when she was very ill. She also complained about a lack of communication and the junior doctor's failure to listen to Mrs A.
I obtained independent advice from a consultant physician. My adviser said that the doctors missed opportunities early in Mrs A's admission to identify the severity and complexity of her conditions, and to reduce the risk and extent of her internal bleeding. He considered that they failed to carry out the appropriate tests and was critical that, given her symptoms and abnormal blood tests, an early referral to cardiology was not made. My adviser said that Mrs A was incorrectly given her warfarin (a drug used to prevent blood clots) when it should have been withheld. As a result, her INR was raised to a high and dangerous level.
The advice I have received is that the staff caring for Mrs A should have considered the potential seriousness of her illness in more detail, and that they failed to properly monitor her condition. I am concerned that advice from a cardiologist was not sought when Mrs A was admitted to the emergency department. It was also not sought at a time when, according to my adviser, signs were very suggestive that she had had a heart attack. I found that better care would have been provided to Mrs A if she had been transferred to the cardiac unit, as she would have received higher levels of monitoring and specialist care at an earlier stage. I am concerned Mrs A's condition was worsened by the care she received, particularly by continuing to administer warfarin when it should have been stopped. I am also concerned that Mrs A's medical history was not documented in enough detail and that the target INR level in her records was incorrect, despite it previously having been set at a lower level by board staff due to Mrs A’s condition.
My investigation found that, given the severity of her illness, Mrs A's outcome may not have been different. However, better care of Mrs A might have increased her chances of survival. It might also have given her family the reassurance that this outcome was despite good medical care, rather than her chances of survival being reduced by poor medical care. In view of the failings identified, I upheld the complaint.
Redress and recommendations
The Ombudsman recommends that the Board:
- apologise to Mrs C for the failings identified in this complaint;
- present this case at a departmental Mortality and Morbidity meeting and report back to the Ombudsman on any learning or improvements that are identified;
- ensure that medical staff involved in this case include this case as a significant event analysis in their annual appraisal; and
- make further attempts to contact doctor 1 and ask doctor 1 to include this case in the educational supervision process of their current post.