The complainant (C) complained to my office about the treatment provided to their late spouse (A) by Lanarkshire NHS Board (the Board).
Following a period of ill health, A attended University Hospital Wishaw’s (UHW) Emergency Department (ED). A was diagnosed with primary biliary cirrhosis (PBC) by the gastroenterology department. A continued to be seen by the gastroenterology department as an outpatient over a period of months. It was noted that A’s liver function had deteriorated over this period.
A then presented to UHW’s ED where they were reviewed and noted to have worsening liver failure. A was subsequently admitted to the Emergency Care Unit (ECU). A was transferred to a specialist liver unit in another NHS Board’s area four days later and sadly died there.
C complained that the Board had failed to adequately investigate and treat A’s condition; that they provided A with inadequate in-patient care and treatment in UHW; and that they failed to treat A with dignity when transferring them to the ECU.
The Board reviewed A’s care by undertaking a Significant Adverse Event Review (SAER). In their SAER, and their written response to C’s complaint, the Board identified service failures. These were failures to timeously refer A to a specialist liver unit, in waiting times, the organisation of A’s care, in the medication prescribed to A, and in staff attitude for which they apologised and identified learning. However, they found no failures in the in-patient care and treatment provided to A in UHW.
During my investigation I sought independent advice from a consultant hepatologist and gastroenterologist. Having considered and accepted the advice I received, I found that:
- A presented with clinical symptoms that were not typical of PBC, and that A had clear indicators of another underlying liver condition.
- Given A’s clinical symptoms the Board have arranged urgent tests and / or a referral to a specialist liver centre / transplant hepatologist within a few weeks of their presentation, and definitely by the time their condition deteriorated several months later.
- In terms of A’s treatment for PBC it is clear that there was a failure to have adequate regard to relevant guidelines. This had significant consequences to As’ health. Six of the seven service standard measures of the PBC guidelines were not met.
- The symptoms that A presented with were also not in keeping with the additional condition that was considered of autoimmune hepatitis (AIH).
- A biopsy should have been offered to A much earlier. When this was subsequently offered, the Board should have done more to actively facilitate A’s attendance for a biopsy. Other appropriate tests to diagnose AIH were not carried out.
- In terms of A’s treatment for AIH, there was a failure to follow the relevant guidelines. In particular in relation to the use of contraindicated steroid medication and a failure to carry out regular blood checks.
- A’s steroid medication was continued, although they were exhibiting side effects, without considering either referral to a specialist, or a liver biopsy or other treatment. There was also a failure to consider if the side effects of the medication were a sign of deterioration of A’s liver disease.
- Although an additional condition of primary sclerosing cholangitis appears to have been suspected and an Magnetic Resonance Cholangiopancreatography (a medical imaging technique) was considered, this was not carried out early enough to exclude or confirm such a diagnosis. Nor were other important tests to differentiate between liver conditions carried out.
- As A’s condition deteriorated acute severe AIH should have been considered and this should have triggered frequent clotting tests and a referral to a transplant unit. This was not done. The clinical team should have recognised that A’s presentation was not in keeping with PBC nor standard AIH.
- If standard treatment guidelines for PBC and AIH had been followed then the outcome for A would have been significantly different and it is possible, if not likely, that A would still be alive.
- There were failures in communication and to adequately take into account A’s personal circumstances.
- There was a failure to provide A with an appropriate level of dignity and person centred care following their admittance to UHW.
- There were significant failings in A’s in-patient care and treatment in UHW. There were failures in the management of A’s ascitic drain, steroid medication, and constipation. There was a failure to trigger a medical review in light of a fall A experienced on a ward.
- Despite significant signs of deterioration and infection during their in-patient admittance at UHW, A’s condition was not given sufficient priority and there was a lack of urgency in making a diagnosis and ensuring that A was provided the correct treatment.
- The Board’s SAER did not adequately address and identify the failings in A’s care and treatment that occurred from their initial presentation.
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There had been a failure to meet the requirements of the Duty of Candour process.
Taking all of the above into account, I upheld all of C’s complaint.
In investigating this case it is of significant concern to me that that I issued an earlier critical public report into the gastroenterology service at UHW on 22 June 2022 (case reference 202001373). In that report I was critical of the care and treatment the patient received from the gastroenterology service for PBC and other clinical issues. In particular I found serious failings in identifying and treating the patient’s deteriorating liver disease between 2017 and 2018. I am concerned that I have found similar failings over a similar timescale in this case.
Recommendations
The Ombudsman's recommendations are set out below:
What are we asking the Board to do for C:
| Rec number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 1 |
Under complaint point a) I found that there was a failure to investigate and/ or diagnose A’s condition. In particular I found that:
Under complaint point (b) I found that the Board failed to provide A with adequate care and treatment as a patient in University Hospital Wishaw between 4 August 2019 and 8 August 2019. Specifically:
I also found that there were failures in the Board’s handling of C’s complaint and the subsequent Significant Adverse Event Review. |
Apologise to C for the failings identified in this investigation and inform C of what and how actions will be taken to stop a future reoccurrence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
|
A copy or record of the apology.
|
We are asking the Board to improve the way they do things:
| Rec number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
|
2
|
complaint point a) I found that the there was a failure to investigate and/ or diagnose A’s condition. In particular I found that:
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Patients showing signs of advanced liver disease should receive appropriate and timely care and treatment that is in line with relevant guidance
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Evidence that the Board have arranged, as a matter of urgency, independent external audit of the treatment of patients by the gastroenterology outpatient service at UHW with PBC/ AIH or an overlap syndrome from 2018 to date to ensure there is no systemic or individual issue which may have affected other patients The audit should be completed independently by individual(s) with the appropriate experience and expertise My office should be provided with an update on the progress of the audit. My office and the complainant should be informed of the results of the audit including all learning points and any required action plan to implement and share findings Evidence that the findings of my investigation have been shared with relevant staff in a supportive manner for reflection and learning Evidence that learning from these events and the external audit is reflected in policy guidance and staff training
|
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3 |
Under complaint point b) I found that the Board failed to provide A with adequate care and treatment as a patient in University Hospital Wishaw between 4 August 2019 and 8 August 2019. Specifically there were failures in the management of A’s ascitic drain, steroid medication, and constipation. We also found that there was a failure to trigger a medical review in light of A’s fall and a failure to follow relevant guidelines in the management of patients with decompensated liver disease. |
Patients admitted to hospital showing signs of advanced liver disease should receive appropriate and timely care and treatment that is in line with relevant guidance |
Evidence that: My findings have been shared with staff in a supportive way for reflection and learning and to ensure similar mistakes are not made again; and That the learning from these events and the external audit is reflected in policy/ guidance and staff training
|
We are asking the Board to improve their complaints handling:
| Rec number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 4 |
I found that the Board’s complaint handling was unreasonable. Specifically:
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When an incident occurs that falls within the Duty of Candour legislation, the Board’s Duty of Candour processes should be activated without delay. Local and Significant adverse event reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. Adverse event reviews should be held in line with relevant guidance.
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Evidence that the Board have reviewed their Duty of Candour processes, including timescales for activating the process and; Evidence that the Board have reviewed their process for carrying out adverse event reviews to ensure these reviews properly investigate, identify learnings and develop system improvements to prevent similar incidents occurring
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We are asking the Board for evidence of action already taken
| Rec number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
|
5
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Under complaint point c) I found that there was a failure to provide A with an appropriate level of dignity and person centred care on 4 August 2019. |
The Board said that they had reminded staff of the professional and caring manner they would expect from them at all times. |
Evidence of the action taken.
|
Feedback
Points to note
As noted at paragraph 81, A should have been referred to a tertiary liver service/ transplant hepatologist within a few weeks of presentation. The failure to do so raises the question in my mind as to whether there is a sufficiently open and transparent culture that encourages clinical staff at all levels to identify when they may require internal or external specialist support in treating complex cases and that enables them to request this. I urge the Board to consider how they can support clinicians to identify and raise when they may require internal or external specialist support when providing care and treatment.
This report will be as difficult for staff to read, as it no doubt is for the family. It is incumbent on the Board to ensure staff are supported and that it is clear to them that my findings reflect failures in systems that should have been there to support them.