Summary
Mrs C complained about the care and treatment that her father (Mr A) received from Dumfries and Galloway NHS Board (the Board) in A&E and in the clinical assessment unit at Dumfries and Galloway Royal Infirmary. Mr A arrived at A&E late in the evening on 2 December 2017. Early in the morning on 3 December 2017, Mr A was admitted to the clinical assessment unit. While in the clinical assessment unit, Mr A had a cardiac arrest and he sadly passed away. The cause of Mr A’s death was a ruptured abdominal aortic aneurysm (AAA).
Mrs C complained that Mr A’s symptoms were not investigated appropriately in A&E. Mrs C also questioned whether the Board’s record-keeping regarding Mr A’s care and treatment was appropriate.
We took independent advice from a consultant in emergency medicine, a consultant in acute medicine and a nursing adviser.
We found that the history and initial examination carried out in A&E were reasonable. However, we also found that the Board failed to perform an ultrasound scan or a CT scan of Mr A’s abdomen in A&E to confirm or exclude a diagnosis of an AAA. If a scan had been done in A&E this may have led to an earlier diagnosis of AAA, Mr A’s transfer to a hospital with a vascular surgical capability (vascular specialists treat disorders of the circulatory system) and the chance of his survival may have been greater.
We found that Mr A was not reviewed promptly by medical staff on his transfer to the clinical assessment unit when he was suspected to have an infection and the nursing documentation and cardiac arrest documentation were not completed reasonably.
In view of these failings, we upheld Mrs C’s complaint that the Board did not provide reasonable care and treatment to Mr A. We also found that the failings in care that our investigation identified could have and should have been established and acted upon during the Board’s own complaints investigation.
Mrs C also complained that the Board did not communicate reasonably with Mr A’s family. We found that Mr A’s family were not kept updated about his deteriorating condition, they were informed in a corridor that he had passed away and clear information was not given about the time of Mr A’s death.
In light of this, we upheld Mrs C’s complaint that the Board did not communicate reasonably with Mrs C and her family regarding Mr A’s care and treatment.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C and her family:
| 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) |
The Board failed to perform an ultrasound scan or a CT scan of Mr A’s abdomen in A&E to confirm or exclude a diagnosis of an abdominal aortic aneurysm. Mr A was not reviewed promptly by medical staff on his transfer to the clinical assessment unit when he was suspected to have an infection. The nursing documentation and cardiac arrest documentation were not completed reasonably. There were failures to communicate reasonably with Mr A’s family |
Apologise to Mrs C and Mrs C’s family for the failure to perform a scan of Mr A’s abdomen in A&E, that Mr A was not reviewed promptly on his transfer to the clinical assessment unit, that the nursing and cardiac arrest documentation were not completed reasonably and that there were failures to communicate reasonably with Mr A’s family |
A copy or record of the apology. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance
By: 19 December 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 Board failed to perform an ultrasound scan or a CT scan of Mr A’s abdomen in A&E to confirm or exclude a diagnosis of an abdominal aortic aneurysm |
Medical staff in A&E should be aware of abdominal aortic aneurysm presentation and investigation
|
Evidence that the findings on this complaint have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions). Evidence that abdominal aortic aneurysm presentation and investigation has been included in A&E staff induction programme. Evidence that guidelines are in place for obtaining imaging when abdominal aortic aneurysm is suspected
By: 13 February 2019 |
| (a) |
Mr A was not reviewed promptly by medical staff on his transfer to the clinical assessment unit when he was suspected to have an infection
|
Patients admitted to the clinical assessment unit who are suspected to have an infection should be reviewed promptly by medical staff |
Evidence that the Board have reviewed the current system for the medical review of patients who are transferred from A&E to the clinical assessment unit and identified areas where this system could be improved
By: 13 February 2019 |
| (a) |
The level of nursing assessment and monitoring that Mr A needed was not recorded on his admission to the clinical assessment unit.
Nursing staff in the clinical assessment unit failed to complete Mr A’s vital signs chart |
Patients admitted to the clinical assessment unit should have their required level of nursing assessment and monitoring recorded.
Patients presenting with moderate pain and signs of shock should have their vital signs checked appropriately following admission to the clinical assessment unit |
Documentary evidence that the findings on this complaint have been fed back to relevant nursing staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).
Evidence that the Board have reviewed the current system for nursing assessment and monitoring of patients admitted to the clinical assessment unit and identified any areas where this system could be improved
By: 13 February 2019 |
| (a) and (b) | The documentation regarding Mr A’s cardiac arrest was unreasonable and this may have led to Mr A’s family being given unclear information about his time of death |
Cardiac arrest documentation should detail:
|
Evidence that the findings on this complaint have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).
Evidence that the Board have reviewed the current system for documenting cardiac arrests in the clinical assessment unit and identified any areas where this system could be improved
By: 13 February 2019 |
| (b) | Mr A’s family were informed in a corridor that he had passed away | Upsetting news should be communicated in a private and quiet area |
Evidence that the Board have reviewed the current system for breaking upsetting news in the clinical assessment unit and identified any areas where this system could be improved
By: 13 February 2019 |
| (a) | The Board’s own investigation did not identify the serious failings in the care provided to Mr A | The Board’s complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (where appropriate |
Evidence that the Board have reviewed why its own investigation into the complaint did not identify the failings highlighted in this report
By: 16 January 2019 |
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
| (b) |
There were failures to communicate reasonably with Mr A’s family:
|
The Board said that they had fed these failings back to the teams in A&E and the clinical assessment unit |
Evidence that the findings on this complaint have been fed back to relevant staff in a supportive way (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions)
By: 16 January 2019 |
Feedback
Complaints handling:
Given that your complaint was received after 1 April 2017, the Board should have been adhering to the NHS Model Complaints Handling Procedure (CHP).
- on 4 January 2018, the Board said that Mrs C made contact with them by telephone to raise concerns about Mr A’s care and treatment.
- on 23 February 2018, a meeting was held to discuss the concerns. The Board state the complaint was closed on 26 February 2018 following the meeting.
The meeting was held 36 working days after Mrs C contacted the Board to make the complaint. The CHP states that meetings should be held within 20 working days of receiving the complaint wherever possible. It is not clear from the records available to me why this meeting was not held within 20 working days of the complaint being received. I have drawn this to the Board’s attention.