Summary
Mrs C complained about the care and treatment her mother (Mrs A) received at Victoria Hospital. Mrs A was admitted to hospital with a suspected infection in her leg, but died shortly afterwards. Mrs C said that the Board gave contradictory and incomplete replies to her questions about Mrs A's treatment. In particular, Mrs C believed that Mrs A's existing longstanding health condition, medications and associated immunosuppression had not been properly taken into account during her treatment. Mrs C was also concerned that medical staff did not communicate reasonably with the family during Mrs A's admission, which meant Mrs A's death had been unexpected and traumatic. Mrs C noted that the Board had failed to respond comprehensively to the questions she had asked, despite multiple meetings with staff, and a protracted correspondence. Finally, Mrs C said that Mrs A's death certificate contained errors, and that the Board had not made an adequate effort to correct these.
We took independent medical advice from a consultant in acute medicine. We found that there were significant failings on the part of the Board. The advice noted that there was no record that the most significant drugs Mrs A was receiving were identified by medical staff or taken into account in her treatment. In addition, although Mrs A had received initial treatment with antibiotics, this had been stopped and there was no detail or reasoning for this recorded in Mrs A's medical records. Following Mrs A death, the Board did not appear to have properly followed its own procedures for reviewing incidents where a patient had come to harm. We considered that Mrs A did not receive a reasonable standard of care and treatment and upheld this aspect of Mrs C's complaint.
We also found that the Board had failed to take reasonable steps to ensure Mrs A's death certificate was accurate. This included a failure to attempt to correct the death certificate. We upheld this aspect of Mrs C's complaint.
In relation to communication with the family, we did not uphold this aspect of Mrs C's complaint. Although we recognised that the family had found Mrs A's deterioration distressing, the standard of communication between medical staff and the family was reasonable.
Finally, we found that the Board failed to handle Mrs C's complaint reasonably and upheld this aspect of her complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
| (a), (b) and (d) |
The Board failed to provide reasonable care and treatment to Mrs A, the Board failed to provide an accurate death certificate for Mrs A and the Board failed to handle Mrs C's complaint reasonably |
Apologise to Mrs C for the failures identified in the report.
The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets |
A copy of the apology.
By: 19 February 2020 |
| (b) |
The Board failed to issue an accurate death certificate for Mrs A |
Issue an accurate Form 11 (new medical certificate of death), so that the family can provide this to the Vital Events Team at the National Records of Scotland |
A copy of the Form 11, with evidence it has been provided to the family
By: 5 February 2020 |
We are asking the Board to improve the way they do things:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
| (a) |
The Board appeared to have failed to follow their own guidance on reporting on adverse incidents and holding SAERs |
Review this case in light of the relevant guidance on SAERs, to determine why this was not followed
|
A copy of the review
By: 19 February 2020 |
| (a) | The Board had failed to resolve the questions over staff access to medical records and the decision to stop antibiotic therapy for Mrs A |
Staff should have access to medical records and other patient information to ensure that treatment takes account of appropriate information at the appropriate time. Decisions about care and treatment should be clearly and accurately documented |
Evidence of a SAER into Mrs A's care and treatment. This should include whether Mrs A's rheumatology records were accessed by medical staff and investigate whether staff were able to access rheumatology records. It should also review the decision to stop Mrs A's antibiotics, to establish why this decision was taken. A copy of the review report should be provided, including any action plans put in place as a result of it
By: 22 April 2020 |
| (b) | The Board failed to issue an accurate death certificate for Mrs A | The Board should have adequate systems in place to ensure that death certificates are accurate when issued |
The Board should demonstrate they have reflected on the mistakes made in Mrs A's case and report any resulting changes to processes for completing and issuing death certificates
By: 4 March 2020 |
We are asking the Board to improve their complaints handling:
| Complaint number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| (d) |
We found the Board's complaint investigation had not answered all the questions raised by Mrs C and had failed to identify and address significant failings on the part of the Board |
The Board should ensure complaint investigations conform to the NHS model complaints handling procedures, particularly in relation to time scales. It should ensure that all the issues raised by complainants are addressed, or explain clearly why it is not appropriate to do so |
Evidence that the Board have reviewed the complaint investigation and established why it failed to respond to all the questions raised, or identify significant failures on the part of the Board. This should include the actions the Board intends to take to improve its complaint handling
By: 4 March 2020 |