Summary
Mrs C complained about the care and treatment provided to her brother, (Mr A) by Lanarkshire NHS Board (the board). Mr A had been experiencing pain in his legs, feet and ankles. He was referred to the deep venous thrombosis (DVT) service at Hairmyres Hospital (the hospital) by his general practitioner and DVT was ruled out as a cause of his symptoms.
Mr A later had a circulation assessment at one of the board's community clinics (the clinic). Staff at the clinic were unable to find a pulse in Mr A's foot. Attempts were made to contact the vascular service at the hospital by telephone but there was no reply and a message was left on an answering service. Mr A returned home. Five days later, however, one of his toes turned black and Mrs C took him directly to the hospital.
A scan showed that Mr A had a blockage in one of the arteries in his thigh and a procedure was suggested to remedy this. The procedure was not carried out for a further three days during which time Mr A became increasingly unwell. This deterioration continued after the procedure and Mr A had to undergo an above the knee amputation of his leg.
During our investigation, we took independent advice from a consultant physician and a vascular surgeon. While we found no issues with the DVT service examination, we identified that the referral pathway from the clinic to the vascular service had failed. We found that this and the delay in conducting the procedure meant that the board had failed to take appropriate, timely action to try to save the limb. While unable to definitively determine that the loss of Mr A's leg was avoidable, we considered more urgent action would have given him the best chance of a different outcome. We upheld Mrs C's complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C and Mr A:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
The referral pathway from the Claudication Clinic to the Vascular Service failed for Mr A |
Provide a written apology which complies with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance |
A copy of the apology letter By: 16 August 2017 |
|
There were delays in the provision of appropriate treatment to Mr A |
Provide a written apology for the delays and the impact this had on Mr A's prospects which complies with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance |
A copy of the apology letter By: 16 August 2017 |
We are asking the Board to improve the way it does things:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
The referral pathway from the Claudication Clinic to the Vascular Service failed for Mr A |
Ensure it has in place an effective referral pathway which has a failsafe, so that urgent appointments are arranged when needed |
Evidence that the referral pathway for urgent care of critical ischemia from the Claudication Clinic to the Vascular Service has been reviewed and, where needed, improved By: 11 October 2017 |
|
There were delays in the provision of appropriate treatment to Mr A |
Ensure timely action is taken when treating critical limb ischemia |
Evidence that this case has been reviewed for learning and improvement within the Vascular Service. This should include any action, or planned action, to apply learning identified By: 11 October 2017 |
Feedback for the Board
Adviser 2's comments on the subjectivity of clinical judgement in assessing pulses should be circulated to relevant staff for learning purposes.