• Case ref:
  • Date:
    September 2013
  • Body:
    Orkney NHS Board
  • Sector(s):
  • Subject:
    communication, staff attitude, dignity, confidentiality
  • Outcome:
    Not upheld, no recommendations


Miss C's sister (Miss A) was admitted to hospital after a fall at home. Miss A had injured her back in the fall, but her GP noted in his referral letter that her health had been declining for some time. She had a history of alcoholism, a number of medical conditions and had been receiving treatment for infections. Although her condition initially improved, Miss A became lethargic and developed symptoms of liver disease. Her condition deteriorated further and she was transferred to a second hospital in a different board area for specialist treatment. Their records indicate that Miss A had pneumonia and had become increasingly confused. She died two weeks after being admitted to hospital. Miss C complained to us that staff at the first hospital did not appropriately assess and treat the cause of her sister's symptoms.

After taking independent advice from one of our medical advisers, we found that Miss A was clearly in very poor health when she was first admitted to hospital. The clinical records showed that her condition was closely monitored and that appropriate investigations were carried out. Although Miss A at first showed signs of improvement she had developed a chest infection, which resulted in her condition deteriorating. We were satisfied that the board took appropriate steps to monitor her symptoms, considered reasonable causes of those symptoms and carried out appropriate diagnostic investigations. We were also satisfied that appropriate treatments were provided and that staff involved specialists from the second hospital at an appropriate stage. We concluded that Miss A's deterioration occurred despite the investigations and treatment provided by the first hospital, rather than as the result of any failure on the part of the board.