Scottish Public Services Ombudsman

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  • Report number:
    201507615
  • Date:
    February 2017
  • Body:
    Lanarkshire NHS Board
  • Sector(s):
    Health
  • Keywords:
    clinical treatment

Summary
Mr C's wife (Mrs A) was admitted by ambulance to Monklands Hospital with increased breathlessness.  While visiting Mrs A, her daughter (Ms B) who is a nurse, reviewed Mrs A's medical records and noticed that it was recorded that Mrs A had been given Amoxicillin, a penicillin antibiotic, earlier in the day.  Mr C said that he had made both ambulance and hospital staff aware that Mrs A was allergic to penicillin and that, previously, penicillin had caused Mrs A to suffer anaphylactic shock.  Mr C said that thereafter Mrs A's condition deteriorated.

Mr C said that although Ms B had immediately informed a member of the nursing staff of the prescribing error, staff had failed to take corrective action and to conduct increased observations of Mrs A.  Mr C said there was also a failure to document the incident in Mrs A's medical records at the time and again when Mrs A was later transferred to the Intensive Care Unit (ICU). Mr C believed there had been unreasonable delay in transferring Mrs A to the ICU where she remained until her death.

Mr C considered that Mrs A had been denied proper treatment for the possible adverse effects of an anaphylactic reaction to the Amoxicillin.  Mr C said that he believed the error in administering Amoxicillin to Mrs A and the lack of an appropriate response could have hastened or brought about Mrs A's deterioration and death.  As a result, Mr C believed that Mrs A had not been provided with a reasonable standard of care and treatment.

The board acknowledged that Mrs A was unreasonably prescribed and administered Amoxicillin when she had a known allergy; that the response of medical and nursing staff was deficient; and there were failures in record-keeping.  The board said that, while Amoxicillin should not have been prescribed or administered to Mrs A, there was no suggestion that an allergic response was seen or was responsible for Mrs A's subsequent clinical course.

During the investigation, my complaints reviewer took independent advice from a consultant in respiratory medicine and a nurse.

Regarding Mr C's complaint that Mrs A was unreasonably given Amoxicillin when she had a known allergy to penicillin, the medical and the nursing advisers said that while what had occurred in Mrs A's case was a human error, the failure by staff to follow drug administration policies was a serious incident and represented serious failings in care.

In respect of Mr C's complaint that staff had failed to take appropriate steps when the prescribing error was reported to them, the medical adviser said that although the board had accepted there were failures in the response of nursing and medical staff to Mrs A wrongly being administered Amoxicillin, these failings fell below an expected standard of care that Mrs A should have received and represented serious failings in Mrs A's care.

Mr C also complained that there was a failure to provide Mrs A with a reasonable standard of treatment. The medical adviser said that the deterioration in Mrs A's condition was due to the worsening of an underlying condition and not to the administration of Amoxicillin.  However, the medical adviser said there were missed opportunities to identify the severity of the deterioration in Mrs A's condition earlier on in her admission and Mrs A should have been referred earlier to the ICU team.  All of which represented a serious failure in Mrs A's care.  I accepted the advice I received.

I was concerned by the serious failings identified in Mrs A's care and treatment and in view of these failings, I upheld all of Mr C's complaints.  I have, therefore, made recommendations to address this.

Redress and recommendations
The Ombudsman recommends that the Board:

  • apologise for the failings identified in complaint (a) in relation to the prescribing and administration of   Amoxicillin when Mrs A had a known allergy to penicillin;
  • ensure the comments of Adviser 1 and Adviser 2 in complaint (a) about the action that requires to be taken to avoid a repetition of what occurred are brought to the attention of relevant staff and to report back on the action taken;
  • carry out a review of the Action Plan and the Board's policies on drug administration in view of the comments of Adviser 1 and Adviser 2 referred to at paragraphs 31, 34 and 35 and to report back on the action taken;
  • provide my office with an update on the work of the Patient Safety Programme;
  • apologise for the failings identified in complaint (b) in relation to the failure to take appropriate action when it was reported that Mrs A had wrongly being administered Amoxicillin;
  • ensure the comments of Adviser 1 and Adviser 2 in complaint (b) are brought to the attention of relevant staff and to report back on the action taken;
  • carry out a review of the Action Plan in view of the comments of Adviser 1 referred to at paragraph 55 and to report back on the action taken;
  • provide evidence to show how they encourage staff to report early when errors occur and how they share the learning from such errors with staff;
  • apologise for the failings in Mrs A's treatment identified in complaint (c);
  • ensure the comments of Adviser 1 and Adviser 2 in complaint (c) are brought to the attention of relevant staff and to report back on the action taken; and
  • carry out a review of the Action Plan in view of the comments of Adviser 1 referred to at paragraphs 95; 96 and 97 and to report back on the action taken.

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Updated: February 15, 2017