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:
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:
- there was a failure to make an appropriate and timely diagnosis;
- there was a failure to appropriately refer A to a specialist liver service/ transplant hepatologist at an early stage in their treatment;
- there were significant and sustained failures in the consideration, management and treatment of A’s deteriorating condition including a failure to take into account relevant guidance; and
- there were failures in communication and to adequately take into account A’s personal circumstances.
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; and
- 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.
I also found that there were failures in the Board’s handling of C’s complaint and the subsequent Significant Adverse Event Review.
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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
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A copy or record of the apology.
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We are asking the Board to improve the way they do things:
| Rec number |
What we found |
Outcome needed |
What we need to see |
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2
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complaint point a) I found that the there was a failure to investigate and/ or diagnose A’s condition. In particular I found that:
- there was a failure to make an appropriate and timely diagnosis;
- there was a failure to appropriately refer A to a specialist liver service/ transplant hepatologist at an early stage in their treatment;
- there were significant and sustained failures in the consideration, management and treatment of A’s deteriorating condition including a failure to take into account relevant guidance; and
- there were failures in communication and to adequately take into account A’s personal circumstances
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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
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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.
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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
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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
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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:
- there was a failure to meet the requirements of the Duty of Candour process; and
- a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements
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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 |
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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.
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Evidence of the action taken.
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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.