Summary
Mrs C complained about the care and treatment provided to her late husband Mr A. Mr A was admitted to Wishaw General Hospital on 24 February 2014 and died there on 6 March 2014. Mr A had been unwell for some time prior to admission and cared for by family members at home. In the days leading up to his admission his condition had deteriorated and he had been hallucinating and unable to swallow. Mrs C complained about a number of the aspects of care provided to Mr A. In their response to her complaint, the board accepted some failings and apologised. Mrs C remained unhappy and asked the SPSO to investigate. I took independent advice from a consultant physician and a nursing adviser.
My investigation found that although her complaint had been upheld, the complaints process had only looked at Mr A's care in a superficial manner. Not all the clinical staff involved in the case had commented and may have been left unaware of the outcome of the board's investigation. I also found a number of significant failings. There was a lack of any overall plan for Mr A's care and treatment, and the treatment he did receive fell well below a level that Mr A should have expected on a number of points. There was no specific assessment of his swallowing difficulties or monitoring of the dehydration that he presented with on admission. Significantly, there was evidence of confusion between staff about whether Mr A was being provided with active or end of life care. Mr A was being proposed for referrals and investigations just two days before palliative care and a possible transfer to a hospice was considered although there was no apparent change in his condition. One doctor noted on file that Mrs C wrongly believed Mr A was dying. However, there is also evidence that other staff did think Mr A was dying and the board acknowledged in their investigation that end of life care would have been more appropriate throughout this admission. Mrs C told us she received conflicting information about his condition and received a call from occupational therapy about physical aids she may need to care for him at home when it should have been clear he would not be discharged. Alongside the failings in the treatment and the confusion around this, I was also critical that there was no evidence Mr A's family were appropriately involved in decision-making. On the day he died, Mr A had a gastroscopy to investigate some of his symptoms. We found that there had been no clear assessment of the risks of such a procedure and further, that, at the time, Mr A did not have the capacity to consent to such a procedure. A certificate of incapacity was in place that allowed medical staff to provide general treatment as Mr A could not legally consent to this. It did not provide for this specific procedure which would normally require additional consent and Mrs C and her family should have been involved in this decision. This means that Mr A was denied safeguards put in place by legislation to protect adults with incapacity when the decision whether or not to go ahead with the gastroscopy was made. Mr A did not recover well from this procedure and, while there was some treatment following his return to the ward, there was little evidence this deterioration was properly assessed.
I found there were also failings around the very sensitive issue of when Mr A had died and who should be informed of his death. The records indicate Mr A died around 13.40 to 13.50. However the death certificate recorded the time as 15.13. This difference happened because it was not until then that a doctor confirmed the death. However, advice by the Chief Medical Officer makes it clear that this approach is wrong and that doctors should seek to put on the certificate as accurate an actual time as possible based on the available information and not simply the time they confirm the death. Following Mr A's death, the decision was made not to notify the procurator fiscal. This assessment was made using a standard checklist. I found no problems with the checklist but it had been wrongly completed and said there were no reasons for Mr A's death to be reported. In fact, Mr A potentially met two criteria – deaths which were clinically unexplained and which may be due to an anaesthetic. Mr A died from unknown causes on the day he had had an invasive procedure and there was evidence he had deteriorated following that procedure. I made a number of recommendations as a result of my investigation. They reflect that some action had been taken by the board prior to my investigation and the significant changes to the procedures around certification of death introduced on 13 May 2015.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mrs C for the failure to report her husband's death to the Procurator Fiscal and the use of an inaccurate time of death;
- (ii) notify the Crown Office and Procurator Fiscal Service of the omission to report Mr A's death to the Procurator Fiscal on 6 March 2014;
- (iii) ensure that all relevant staff are aware of the current requirements for reporting a death to the Procurator Fiscal;
- (iv) ensure that relevant staff are aware of the Code of Practice for practitioners authorised to carry out medical treatment under Part 5 of the Adults with Incapacity (Scotland) Act 2000;
- (v) present this case and the findings of this report at a medical/respiratory departmental meeting; and
- (vi) ensure that this case is included in the appraisals of the relevant consultants and the educational portfolios of relevant trainee staff.