The complainant (C) complained to my office about the treatment provided to their late sibling (A) by Lothian NHS Board (the Board). A was 51 years old. They ruptured the patella tendon of their left knee in a fall and underwent surgery at Royal Infirmary of Edinburgh (RIE) to repair the patella tendon tear. They were discharged the following day with a hinged knee brace and instructed to weight bear as able to.
A attended the Orthopaedic Fracture Clinic for follow-up review two weeks later, as arranged. The clips were removed from the wound and a plan was made for A to progress gradually with a hinged knee brace with follow up in clinic four weeks later.
A died suddenly at home the day after attending the Fracture Clinic. Following investigation by the Scottish Fatalities Investigation Unit (SFIU), A’s cause of death was found to be:
- 1a) pulmonary thromboembolism,
- 1b) deep vein thrombosis (DVT) and
- 1c) recent leg surgery
C complained that A was not appropriately assessed and treated for blood clot risk.
In their complaint response the Board said that A’s blood clot risk was assessed. They said A was not prescribed blood-thinners as they had no high-risk features for blood clots and had no weight-bearing restrictions placed upon them. When A attended the fracture clinic for review, they were not displaying any signs or symptoms of a DVT or pulmonary embolism (PE), such as leg or thigh swelling, calf pain, chest pain or shortness of breath.
In response to our enquiries the Board acknowledged that there was no record of a risk assessment having been carried out. The Board said a further investigation by the service identified that A was in fact prescribed and administered one dose of DVT/ anticoagulant medication. They apologised for the inaccurate information previously provided but provided no further evidence or documentation in support of their position.
The Board said that the case was discussed at the Trauma Department morbidity and mortality meeting and there was agreement that post-operative pulmonary embolism is a recognised complication of lower limb surgery and no alteration in practice was recommended.
During my investigation I took independent advice from a consultant orthopaedic surgeon (specialist in conditions involving the musculoskeletal system).
Having considered and accepted the advice I received, I found that the Board:
- failed to carry out a risk assessment for A’s blood clot risk.
- failed to note A’s BMI (body mass index) of >/= to 30, which was a risk factor.
- failed to identify the additional risk associated with the anaesthesia time, which in A’s case was in excess of 90 minutes.
- did not have a venous thromboembolism (VTE) prophylaxis protocol in place in their orthopaedic department.
- failed to undertake a Significant Adverse Event Review (SAER) for an unexpected death, in line with national guidance.
I also found failings in the Board’s complaints handling:
- the Board’s complaint response sought to provide reassurance that A’s personal blood clot risk was assessed, and that A did not have any high-risk features despite there being evidence which clearly indicates this was not the case.
- the Board provided conflicting accounts in relation to whether A received anticoagulant medication.
Taking all of the above into account, I upheld C’s complaint.
Recommendations
The Ombudsman's recommendations are set out below:
What are we asking the Board to do for C:
| Rec number | What we found | What the organisation should do | What we need to see |
|---|---|---|---|
| 1 |
Under this point of the complaint I found that the Board’s treatment fell below a reasonable standard. In particular I found that the Board should have:
I also found it was unreasonable that the Board did not have in place a relevant VTE policy for the orthopaedic department and that the Board’s complaint handling was unreasonable. |
Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets |
A copy or record of the apology. By: 24 June 2024 |
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 |
Under this this point of the complaint I found that the Board’s treatment fell below a reasonable standard. In particular I found that the Board should have:
|
Patients undergoing orthopaedic surgery should be appropriately risk assessed for VTE. This should include an assessment of BMI and anaesthetic time. The assessment should be documented on the clinical record. |
Evidence that the Board have: carried out a sample audit of orthopaedic trauma patients at RIE to ensure that the assessment and documentation of risk for VTE is being appropriately carried out. Details of the findings of the audit and any actions identified to be included. reviewed the training needs for relevant staff in relation to the assessment and documentation of risk for VTE. Details of the review findings and how any actions identified will be taken forward to be included. shared the findings of my investigation with relevant staff in a supportive manner for reflection and learning. By: 22 August 2024 |
| 3 | A Significant Adverse Event Review for an unexpected death should have been held in line with national guidance. | Where adverse event(s) occur an adverse event review should be held in line with relevant guidance to ensure there is appropriate learning and service improvements that enhance patient safety. |
Evidence that the Board’s systems for carrying out critical and adverse event reviews have been reviewed to ensure they are carried out in line with national guidance. By: 22 August 2024 |
We are asking the Board to improve their complaints handling:
| Rec number | What we found | Outcome needed | What we need to see |
|---|---|---|---|
| 4 | There was a failure to fully investigate and identify the significant failings in this case in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. The complaint response also contained inaccuracies in relation to the assessment of A’s risk for VTE. | Complaints should be investigated and responded to in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning. The complaint response should be factually accurate. |
Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions). By: 22 July 2024 |
Evidence of action already taken
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 |
|---|---|---|---|
| a) | The Board should have had a relevant VTE protocol for the orthopaedic department in place. | The Board told us they were drafting a protocol. |
Evidence of the VTE protocol and any supporting documents. By: 22 July 2024 |
Feedback
Points to note
My investigation found the medical records in relation to whether anticoagulation was prescribed and given to be unclear. This is unsatisfactory. I am highlighting this for the Board to reflect on and action as required. I expect the Board to give this serious consideration.