Summary
Mrs A was transferred from Victoria Hospital, Kirkcaldy, which is the responsibility of Fife NHS Board, to the Royal Infirmary of Edinburgh for heart surgery. Following one postponement in mid-December, the operation went ahead on 21 December 2012. Mrs A's niece (Mrs C) said that two days after the operation, her aunt was having a blood transfusion shortly after which she began to very rapidly decline. Mrs A was admitted to intensive care and died on 26 December 2012. The cause of Mrs A's death was recorded as multi-organ failure due to sepsis of unknown source in association with recent prosthetic aortic valve replacement and known ischaemic heart disease (a condition that affects the supply of blood to the heart). Mrs C complained that her aunt did not receive appropriate care and treatment from Lothian NHS Board.
In investigating this complaint, I took independent clinical advice from a cardiothoracic surgeon (specialising in chest, heart and lung surgery). The advice I received was that the heart surgery appeared to have been performed to a high standard, and Mrs A's initial recovery was good. Following a routine observation, Mrs A was recommended to have a blood transfusion. Her condition quickly deteriorated, and the board said that staff suspected a transfusion reaction and implemented their procedures for this. My adviser said that all teams reacted appropriately and promptly in response to Mrs A's condition.
Tests were taken to determine the cause of Mrs A's change in condition and I am satisfied that the blood Mrs A received was not contaminated. Her deterioration was coincidental with her developing a bacteria entering into her blood stream in association with sudden acute liver failure. However, I understand that it must have been very distressing for Mrs A's family to witness her sudden deterioration given the early signs that her heart surgery had been successful.
My investigation identified a number of areas that I am critical of. My adviser told me that communication between the two hospitals treating Mrs A should have been better given her status as a high-risk patient with other pre-existing medical conditions and a history of previous heart surgery. Related to this, given Mrs A's case was a high-risk and complex case, this should have been discussed at a pre-operative multi-disciplinary team meeting, which did not happen – the board said that when Mrs A was transferred to the Royal Infirmary she was fit for surgery and there were no alternative treatments to discuss.
My adviser noted that some documentation was not completed appropriately, particularly around consent for the procedure. Following Mrs A's death, there is no evidence that her GP was notified, as should have happened. I also acknowledge that there was an early retraction of Mrs A's death certificate which, according to my adviser, had been inappropriately completed by a junior doctor. I recognise the additional distress that this would have caused Mrs A's family.
Finally, during the course of my investigation I identified that there was a positive result from an umbilical (navel) swab taken on 12 December 2012, the day of the initial scheduled operation, which may have been the source of the subsequent bacteraemia (the presence of bacteria in the blood) and septicaemia responsible for Mrs A's death. My adviser said that although the positive result was acted upon and antibiotics prescribed to Mrs A, it is not apparent that the potential relevance of this positive finding for Mrs A, who was who was due to undergo high-risk re-do cardiac surgery, was fully realised by the cardiac team treating her and whether consideration was given to potentially delaying Mrs A's surgery in view of the risk of the subsequent sepsis.
I made a number of recommendations to address the failings I identified in the care and treatment provided to Mrs A. I also found that the board's handling of Mrs C's complaint was not reasonable. There were delays in responding which I accept the board have apologised for, but the apology letter was brief, lacked empathy and did not fully address the reasons for the delay. I note, however, that process changes have since been implemented so I have not made a recommendation about this.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that the comments of the Adviser in relation to the issues of consent and proper and accurate record-keeping are brought to the attention of the relevant staff and a review is carried out; 30 November 2015
- (ii) ensure the comments of the Adviser in relation to the positive umbilical swab taken from Mrs A on 12 December 2012 are brought to the attention of relevant staff and they reflect on this; 30 November 2015
- (iii) apologise to Mrs C and the other members of Mrs A's family for the failings identified in complaint (a); and 30 October 2015
- (iv) apologise to Mrs C and Mrs A's daughter for the failings identified in the apology letter initially issued to Ms A's family. 30 October 2015
The Ombudsman recommends that the Board and Fife NHS Board:
- (v) ensure the comments of the Adviser in relation to the lack of clear cardiology referral documentation between Hospital 1 and Hospital 2 are brought to the attention of relevant staff. 30 November 2015