The complainant (C) complained to my office about the care and treatment provided to their late grandparent (A) by Lanarkshire NHS Board (the Board).
A arrived at the Emergency Department of University Hospital Monklands by ambulance in the afternoon of 11 June 2022 and was admitted to hospital in the early hours of 12 June 2022.
While in hospital, A’s condition deteriorated. Over the course of the evening of 12 June 2022, A became seriously unwell. A vomited, developed abdominal pain, and had a distended abdomen. A received abdominal x-rays and input from the surgical team, and staff attempted to stabilise A.
A small bowel obstruction (narrowing or blockage in the bowel, which usually requires urgent treatment) was identified in the early hours of 13 June 2022. Sadly, A died a short time later.
C complained to me (having been though the Board’s complaint process) about the events preceding A’s death. In particular, C complained about events relating to the assessment of A on admission and that communication with A’s family prior to A’s death was unreasonable.
The Board reviewed this case again after receiving notification of my investigation and identified some areas for improvement. They determined that further investigation through a Significant Adverse Event Review (SAER) was not required.
During my investigation I took independent advice from a Consultant in Acute and General Medicine. Having considered and accepted the advice I received, I found that:
Care and treatment
- An abdominal x-ray should have been carried out when A was admitted to hospital in the early hours of 12 June 2022 on the basis of A’s presentation and also as part of an assessment for Clostridium difficile (C. diff, an infectious disease) as set out under relevant national prescribing guidelines.
- It was unreasonable that there was no record of an abdominal examination by a consultant on the morning of 12 June 2022 given an abdominal examination should have been carried out and documented based on A’s presentation.
- The Board’s failure to carry out an abdominal x-ray on admission and the lack of evidence that an abdominal examination was carried out by the consultant on the morning of 12 June 2022 means that the opportunity to detect signs of bowel obstruction was missed at an earlier stage when A was stable enough to undergo life-saving treatment. Therefore, there is a prospect that A might have survived.
Communication
- On balance, I found that the Board’s communication with A’s family was reasonable.
Taking all of the above into account, I upheld C’s complaint about A’s care and treatment. I did not uphold C’s complaint about the Board’s communication.
I was also critical that a SAER was not held in this case given it related to an unexpected death and given the Board’s review had identified three specific points where consideration should be given to escalating to a SAER.
Finally, I found the Board’s handling of C’s complaint was unreasonable.
Further comment
It is of concern to me that I have made similar findings regarding Health Boards not carrying out adverse event reviews in other recent public reports (case references 202100979; 202209575; 202100560; 202101928; 202105840; 202200588). I intend to write to the Scottish Government and Health Improvement Scotland to draw their attention to the findings and recommendations I have made in relation to adverse event reviews in recent cases, including this one.
Recommendations
The Ombudsman’s recommendations are set out below:
What we are asking the Board to do for C:
|
Rec number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
1. |
Under complaint point a) I found the Board’s care and treatment fell below a reasonable standard. In particular I found the Board should have:
|
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/meaningful-apologies |
A copy or record of the apology. By: 19 March 2025 |
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 complaint point a) I found the Board’s care and treatment fell below a reasonable standard. In particular I found the Board should have:
|
Patients presenting with diarrhoea and vomiting should have their symptoms fully assessed and be appropriately examined in a timely manner in line with relevant guidance. |
Evidence the findings of my investigation has been shared with relevant staff in a supportive manner for reflection and learning. By: 16 April 2025 Evidence that the Board have reviewed their guidance for the screening of C. diff to ensure it is in line with national guidance in relation to the carrying out of an x-ray with details provided of any changes and how this will be disseminated to staff. Evidence that the Board have reviewed their guidance for clinical staff in the medical assessment unit in relation to the carrying out of abdominal examinations and x-rays and the recording of findings with details provided of any changes and how this will be disseminated to staff. By: 16 May 2025
|
|
3. |
The Board’s review into A’s case following notification of my investigation did not identify all of the significant failings in care and areas for improvement, including that this was a potentially preventable death. The Board did not appropriately consider carrying out a SAER. |
Reviews into patient care should be undertaken at the right time, identify failings and good practice, and findings and recommendations are followed up, to demonstrate learning. Where adverse event(s) occur a significant adverse event review should be held in line with the Board’s protocols and national guidance to ensure there is appropriate learning and service improvements that enhance patient safety. |
Evidence the findings of my investigation has been shared with relevant staff in a supportive manner for reflection and learning. By: 16 April 2025 Evidence that the Board’s systems for carrying out significant adverse event reviews have been reviewed to ensure they are carried out in line with the Board’s protocols and national guidance. By: 16 May 2025 |
We are asking the Board to improve their complaints handling:
|
Rec number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
4. |
The Board’s complaint handling was unreasonable. In particular I found the Board should have:
|
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. |
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: 16 April 2025 |
Evidence of action already taken
The Board told me they had already taken action to address the issues and provided me with an action log which I am satisfied are reasonable. I will ask them to confirm that all actions are now complete and for an explanation about how they will assess their effectiveness going forward. (By 16 April 2025)
Feedback
Points to note
In the advice I took (and accepted), the Adviser said that:
- the Emergency Department Nursing Record (which recorded a history of diarrhoea and vomiting) provided very useful additional information that - had it been used - may have guided the team towards earlier investigation and management;
- the record made by a junior doctor who admitted A to the MAU included a picture of a hexagon to signify the abdomen, with an arrow through it, to indicate everything was fine. The Adviser said this record is not detailed, does not address bowel sounds and does not record what the doctor found, only showing that nothing was abnormal. The Adviser said that, while not unreasonable, this is a concern; and
- A should have been nursed in a side room until potentially infective diarrhoea or vomiting was excluded.
I am drawing these points to the Board’s attention and encourage them to consider and reflect on them, and whether there is scope for further learning from them.