Summary
Ms C complained about the treatment provided to her late mother (Mrs A). Mrs A was 53 years old when she attended at Aberdeen Royal Infirmary (the hospital) with lower abdominal pain and urinary frequency. She was discharged with plans for urgent follow-up. Before this took place, Mrs A was re-admitted via the emergency department. She was found to be suffering from cancer and procedures to insert plastic tubes into her kidneys to drain urine were necessary. The procedure, called nephrostomy, is carried out when the tube linking the kidney to the bladder has become blocked. After the nephrostomies were carried out, Mrs A later began to show signs of infection. Although antibiotic treatment was started, Mrs A developed sepsis (a severe complication of infection) and died.
Ms C complained that Mrs A had not been prescribed prophylactic antibiotics (antibiotics given as a precaution to prevent, rather than treat, an infection) prior to the nephrostomies. The board initially responded that there was no requirement to prescribed these and Ms C brought her concerns to this office for investigation. A short time later, the board advised us that a hospital policy recommending the use of prophylactic antibiotics had been identified. We suspended our investigation to allow the board to address this matter and a number of further issues Ms C raised. After the board issued their final response, Ms C brought the complaint back to this office and we restarted our investigation.
We took advice from a consultant urologist. We found that there had been a failure to follow the hospital policy on prescription of prophylactic antibiotics for Mrs A. We established that Mrs A had a poor prognosis due to the extent of her cancer. While prescribing prophylactic antibiotics may have prevented her from developing sepsis, it was impossible to definitively determine the effect they would have had.
Although the board latterly acknowledged its policy had not been followed, no apology was offered to Ms C for either the failing itself or for the fact its initial complaint response was inaccurate. We upheld Ms C's complaint and made a number of recommendations to address the issues identified.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Ms C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
The Board acknowledged that the local recommendation to prescribe prophylactic antibiotic was not followed but has not apologised |
Apologise to Ms C for the failure to follow local guidance. 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: 20 October 2017 |
|
The initial complaint response gave inaccurate information on the prescription of prophylactic antibiotics for nephrostomies |
Apologise to Ms C for not giving a full and accurate response. 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: 20 October 2017 |
We are asking the Board to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
|
The Board has advised its intent to review the local policy on prescribing prophylactic antibiotics for nephrostomies |
The local policy should provide clear guidance to clinicians on when prophylactic antibiotics are to be prescribed and by whom |
Evidence that the policy has been reviewed including the choice of antibiotic, length of prescription and clear definition of the clinician responsible for prescribing By: 20 November 2017 |
|
At the time of Mrs A's admission and the initial complaint response, staff were not following local policy |
All relevant clinicians should be aware of the guidance |
Evidence, such as memos, emails, training resources, to confirm that awareness of the policy has been raised with relevant staff By: 20 December 2017 |
Feedback
Complaints handling
Due to new issues being raised by Ms C, this investigation was suspended to allow the Board to respond. By this time, the Board had recognised that there was, in fact, a local recommendation to prescribe prophylactic antibiotics for patients like Mrs A. This represented an opportunity for the Board to acknowledge that its original response was inaccurate and apologise. More effective handling of this complaint could have resolved the matter for Ms C at an earlier stage without the need for this further investigation. The Board should reflect on this.