Decision Report 201300126

Summary

Mr C's late wife (Mrs C) had chronic obstructive pulmonary disease (a disease affecting the lungs). She was admitted twice in one month to Forth Valley Royal Hospital with pneumonia and treated with antibiotics. The following month she was admitted for another two days with vomiting and diarrhoea. During this last admission, tests showed abnormal temperature and blood results. On the day of her discharge, Mrs C felt very unwell and an advanced nurse practitioner found a wheeze in her right lung, but the consultant who reviewed Mrs C decided to discharge her. Mrs C's condition continued to deteriorate and she was admitted to another hospital five days later where pneumonia was again diagnosed. After being discharged from there, she developed a severe infection and irregular heartbeat and was diagnosed with an inflammatory condition of the bowel. She sent us her complaint but died before we could investigate it, and her husband carried it on on her behalf.

Mr C complained that the consultant's decision to discharge Mrs C after the episode of vomiting and diarrhoea was unreasonable in light of her symptoms, and said that further investigations should have been carried out. He also complained that the advanced nurse practitioner's findings were unreasonably dismissed and that these failures led to a prolonged period of suffering for Mrs C before she was properly diagnosed and received appropriate treatment. Finally, Mr C complained about the board's complaints handling.

We took independent advice on Mr C's complaint from one of our medical advisers, who agreed that Mrs C's discharge should have been delayed for further investigation of her symptoms, and of the abnormal temperature and blood test results. We found that Mrs C was discharged with no clear diagnosis and that she endured symptoms for longer than she should have before she was diagnosed and treated appropriately. The adviser said that the consultant who discharged Mrs C had to make a difficult decision, and was seeing Mrs C for the first time. He said that responsibility for the decision should be viewed as an overall system failure involving several healthcare professionals who had been responsible for Mrs C's care.

We found that the board at first failed to fully respond to the complaints, but then fully addressed them after receiving a further letter from Mrs C. We appreciated that Mr C disagreed with the board's response and, as indicated above, we reached a different view to that of the board on the reasonableness of Mrs C's discharge. However, that is not evidence in itself of administrative fault by the board in their complaints handling, and we were satisfied that the board's interpretation of the complaints was reasonable. We, therefore, found that on the whole the board reasonably investigated the complaints.

Recommendations

We recommended that the board:

• review the ward round procedures to investigate and address why medical staff were unaware of Mrs C's temperature and why it was not discussed;
• review the investigation process to ensure that abnormal results are highlighted and considered; and
• apologise to Mr C for the failures identified.