Summary
Mrs C complained about the care and treatment that staff at Queen Elizabeth University Hospital (the Hospital) provided to her late husband, Mr A.
Mr A previously received hip replacement surgery at the Hospital and was discharged. He was given clexane on the ward and aspirin on discharge as prophylaxis (preventative medication) to reduce the risk of venous thromboembolism (VTE - blood clots that start in the vein), including pulmonary embolism (a sudden blockage in a major artery).
Approximately three weeks later, Mr A suffered a sudden bleeding from his bowels. He was re-admitted to the Hospital with a suspected upper-gastrointestinal bleed. Staff carried out an endoscopy (a procedure to look inside the oesophagus, stomach and first part of the small intestine) and took blood tests. A sigmoidoscopy (a procedure that involves looking inside the large intestine) could not be carried out. The next evening, Mr A suffered a sudden collapse and died as a result of a cardiac arrest caused by a pulmonary embolism.
Mrs C raised concerns about the medical and nursing care provided to Mr A, including the investigations carried out, a decision not to give a blood transfusion, monitoring, and the events surrounding his death.
We took independent advice from three clinical specialists: an orthopaedic surgeon, a consultant in acute medicine and a nurse.
As the cause of death was pulmonary embolism, we investigated the VTE prophylaxis given to Mr A during his first admission to the Hospital. We found VTE prophylaxis in the Hospital was appropriate, but discharge on aspirin was not supported by national guidance and the Board’s own guidelines were not followed. We noted that there is no completely effective way of preventing pulmonary embolism; however, providing appropriate medication could have reduced the risk to Mr A. We were unable to rule out the possibility that this failing may have contributed to Mr A’s death. We also found there was an apparent lack of consultant involvement in Mr A’s pre-operative management.
Our investigation found medical care during the second admission was reasonable. We noted this was a complex admission, but the correct investigations were carried out and it was appropriate not to give a blood transfusion. We found medical staff did not miss any warning signs of the pulmonary embolism, noting that pulmonary embolism can occur suddenly, without warning, and with no obvious signs.
We found that nursing care during the second admission was unreasonable. In particular, there was a failure to record repeat observations for the evening Mr A died. We also noted, as the Board acknowledged, the difficult circumstances surrounding Mr A’s death could have been handled more sensitively by some staff.
We upheld Mrs C’s complaints 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 Mrs C:
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What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
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There was a failure to provide appropriate medication to reduce the risk of blood clots following Mr A’s discharge from the Hospital.
Mr A’s National Early Warning Score observations were not adequately recorded on 13 June 2016 and there was a failure to re-check his capillary blood glucose levels |
Apologise to Mrs C for failing to provide Mr A with appropriate medication and to carry out appropriate nursing observations and blood glucose checks.
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 September 2018 |
We are asking the Board to improve the way they do things:
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What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
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Aspirin alone was prescribed to prevent blood clots on discharge, contrary to the Board’s guidance and national guidance
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Patients should be prescribed prophylactic blood clot prevention medication following hip fracture surgery, in line with the Board’s guidelines and national guidance |
(1) Documentary evidence that the orthopaedic team have been made aware of the case and considered it for relevant learning at an appropriate meeting (such as a minute from an orthopaedic morbidity and mortality meeting).
(2) Documentary evidence that the Board has taken steps to ensure that relevant staff are aware of and take into account the guidance on venous thromboprophylaxis in their clinical practice.
By: 22 October 2018
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Theatre notes and the prescription form were not completed appropriately.
There is no record of pre-operative consultant involvement in Mr A’s medical management during his admission in May 2016, prior to his surgery.
The Board did not provide all of the relevant records until after the circulation of the draft of this report |
Theatre notes and prescription forms should be adequately completed.
Patients admitted for hip fracture surgery should receive an appropriate level of consultant involvement in their pre-operative care. This should be properly recorded in the medical records.
The Board should ensure that clinical evidence demonstrating the treatment and care provided is provided at the appropriate point in an SPSO investigation |
(3) Documentary evidence that this has been fed back to relevant staff in a supportive manner that encourages learning. By: 22 October 2018 (4) Documentary evidence that this has been fed back to relevant staff in a supportive way that promotes learning.
By: 22 October 2018
(5) Documentary evidence of the steps the Board will take to ensure all relevant clinical evidence is provided at the appropriate point of an SPSO investigation By: 22 October 2018
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There was a failure to carry out repeat National Early Warning Score (NEWS) observations. Observations following the endoscopy were not charted on NEWS. Capillary blood glucose levels were not re-checked
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Patient observations should be appropriately taken and charted
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(1) The Board should demonstrate that they have reviewed their policy for recording observations after a procedure and on return to the ward area.
(2) The Board should demonstrate that the monitoring issues have been discussed with relevant nursing staff in a supportive way that promotes learning (such as a minute from a relevant ward/unit meeting)
By: 22 November 2018 |
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
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What we found |
What the organisation say they have done |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
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The Board accepted that nursing staff did not deal sensitively with providing Mr A's death certificate |
The Board said that staff would reflect on this |
Evidence that this has happened
By: 22 October 2018 |
Feedback
Communication
I urge the Board to reflect on how they communicate with families, particularly in sensitive and difficult situations such as the death of loved ones. In doing so, it would be appropriate to consider what use is made of resources such as death and dying teaching and written resources such as the Scottish Government’s publication ‘What to do after a death’, to support the families of patients at such difficult times.