Summary
Mr C complained about the care and treatment his late wife (Mrs C) received from the Emergency Department at Monklands Hospital (the hospital) when she attended with abdominal pain. Mr C was concerned that Mrs C had been discharged home during the early hours of the morning without being assessed properly and that she was in pain.
We took independent advice from two clinical specialists, including a consultant in emergency medicine and a consultant in emergency general surgery. We considered that the clinical assessments and record-keeping by two different doctors who reviewed Mrs C fell below a reasonable standard. In addition, we found that there was no evidence to demonstrate that Mrs C had been offered pain relief despite it having been documented that she was experiencing moderate to severe pain.
We also found that a significantly abnormal blood test result had been overlooked by the board on three separate occasions: at the time Mrs C was discharged from hospital; when providing clinical information to the Crown Office and Procurator Fiscal Service's forensic pathologist; and when investigating Mr C's complaint. We considered that, had a more senior doctor overseen Mrs C's care, and due attention been given to this test result, she would have been admitted to hospital which may have avoided her death.
In terms of Mrs C being discharged home during the early hours of the morning, we considered this unreasonable given Mrs C was an elderly, frail woman with multiple health problems. We were critical that hospital staff did not communicate with Mr C about the discharge and that the paperwork which prompts such discussions had not been completed appropriately.
We upheld both complaints and made a number of recommendations to address the issues identified. The Board have accepted the recommendations.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) and (b) |
I found that there were unreasonable failings in Mrs C's care and in the Board's investigation of the complaints |
Provide a written apology to Mr C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at https:www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology By: 24 January 2018 |
We are asking the Board to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) |
The quality of the clinical assessments and documentation by both doctors was of an unreasonable standard |
Patients should receive a full assessment with all relevant information documented including: medical and medication history; and observations |
Confirmation that both doctors have been made aware of the findings and had the opportunity to discuss and learn from them, including reference to any learning and development, or training, identified By: 21 February 2018 |
|
(a) |
Staff failed to perform a 12-lead ECG. |
A 12-lead ECG should be used in the assessment of abdominal pain in similar cases |
Evidence that relevant staff have undertaken educational activities to better understand cardiovascular disease in women and what action to take in future By: 21 February 2018 |
|
(a) |
Mrs C's discharge from hospital was not overseen by a more senior doctor and an important blood test result was overlooked |
Patients should not be discharged without senior doctor oversight in similar cases. All relevant results should be taken into account |
Confirmation that Doctor 2 has been made aware of the findings and had the opportunity to discuss and learn from them, including reference to any learning and development, or training, identified By: 21 February 2018 |
|
(a) |
The Board failed to provide COPFS with the serum amylase test result |
All relevant test results should be identified and provided to COPFS |
Evidence that the Board have now sent this result to COPFS Evidence that staff have been reminded of the importance of providing all relevant information at the relevant time By: 21 February 2018 |
|
(a) and (b) |
The Board's investigation of the complaints was not robust and failed unreasonably to identify the abnormal serum amylase test result |
Clinicians providing input to complaint investigations should thoroughly review the care provided |
Evidence that these findings have been shared with Doctor 3 with appropriate support By: 21 February 2018 |
|
(b) |
It was unreasonable to discharge Mrs C without contacting Mr C in advance |
The discharge section of the clinical records should be completed in terms of relative/next of kin contact in all cases |
Evidence that the Board has a process in place for auditing discharge documentation Evidence that my decision has been shared with relevant staff with appropriate support By: 21 February 2018 |