Summary
Mr C, an advocacy worker, complained about the care and treatment Mr A received during and following an admission to Dr Gray's Hospital, Elgin. Mr A was admitted in a critically ill state, suffering from sepsis due to a chest infection; alcohol withdrawal; and possible effects of malnutrition. The sodium levels in his blood were noted to have been dangerously low and he was prescribed intravenous (IV) fluids to try to raise them. However, as a result of the sodium levels rising too quickly, Mr A developed a neurological condition known as osmotic demyelination syndrome and was left profoundly incapacitated. Mr C complained that Mr A's incapacity, which includes profound speech problems and walking difficulties, was as a result of inappropriate administration of IV fluids.
We took independent medical advice from a consultant physician, who did not consider that Mr A's sodium levels were adequately monitored. They noted that there were long periods between reviews of blood tests and no evidence that Mr A's fluid prescription was ever adjusted according to his sodium levels. They said that the rapid rise in sodium levels did not appear to have been considered at all until neurological deterioration was apparent. We accepted this advice and upheld the complaint. We were critical of the board for not having proactively arranged to formally review Mr A's care given the unfortunate outcome, and for not having identified learning points following their investigation of Mr C's complaint.
Mr C also complained that, when Mr A was formally certified as not having had capacity to make decisions about his medical treatment, the board did not appoint an advocate. We noted that subsequent discussions about Mr A's care and treatment were documented with his daughter (Miss A) and other relatives. We were advised that, as Mr A had living relatives and was not without representation, there was no requirement to appoint an advocate. We did not uphold this complaint. In addition, Mr C complained that a decision not to resuscitate Mr A in the event of heart or lung failure was not discussed with Miss A. Although the extent to which this was discussed with Miss A was not clear, it appeared that she was made aware of the decision retrospectively. We were advised that it would be reasonable for medical staff to take such a decision, and discuss it with family afterwards, if there is sudden deterioration at a time when family could not be reached. However, this was not the case with Mr A and his poor health was chronic in nature, with no signs of recovery over time. We, therefore, concluded that there was an opportunity for the decision to have been discussed and agreed with Miss A prior to it being taken. Given this, and the fact that there was no clear evidence of an explicit discussion afterwards, we upheld this complaint.
Finally, Mr C also complained about a lack of medical review following Mr A's discharge, noting that he had not had any further contact from the hospital. We were advised that hospital follow-up would only be arranged if there was any potential benefit from review in a specialist led clinic. In Mr A's case, we were informed that there was no routine requirement for further medical input and that any necessary medical interventions for complications could reasonably be handled by his GP. We, therefore, did not uphold this complaint. However, we noted that the discharge arrangements did not appear to have been made clear to Mr A. While these were set out in the discharge letter that was sent to his GP, we identified that this was not sent until almost four months after discharge. We considered this unacceptable and made some further recommendations.
Redress and recommendations
The Ombudsman recommends that the Board:
- carry out an adverse event review of this care episode, taking account of the failings this investigation has identified, and inform us of the steps they have taken to avoid a similar future occurrence;
- apologise to Mr A for their failure to appropriately manage his fluid intake and for the serious impact this failing has had on his health and quality of life;
- carry out a review of the DNACPR process and take steps to ensure that these decisions are appropriately discussed with patients' representatives, where possible;
- apologise to Mr A and Miss A for failing to appropriately discuss the DNACPR decision with Miss A;
- provide us with an assurance that processes are in place to avoid similar future delays in discharge summaries being sent to GPs; and
- apologise to Mr A for the delay in sending the discharge summary to his GP.