Decision Report 201507722

Summary

Mrs C's mother (Mrs A) was admitted to the Medical Assessment Unit (MAU) at Dumfries and Galloway Royal Infirmary via A&E after showing signs of a stroke. Whilst in hospital, Mrs A suffered a major stroke. Mrs C raised a number of complaints about the board, including that they unreasonably failed to give Mrs A a clot buster rtPA (an injection to break down blood clots) and that nursing staff failed to monitor Mrs A appropriately.

We obtained independent medical advice from a consultant physician and a nurse. The medical adviser said that the board unreasonably failed to give Mrs A a clot buster rtPA, although they said that the decision would have been a difficult one and would have had to have been made by a specialist.

In addition, the medical adviser said that when Mrs A was in A&E, the board should have carried out a specific risk categorisation using the ABCD2 score (a risk assessment tool designed to improve the prediction of short-term stroke risk after a 'mini stroke'). Had they done so, this would have shown that Mrs A was at very high risk of progression to acute stroke. The medical adviser also said that Mrs A should have been admitted to an acute stroke unit and given a carotid Doppler (a scan to detect a narrowed artery in the neck, which may cause a stroke). She should also have been monitored continuously by experienced staff, rather than being admitted to the MAU. The medical adviser also said that a plan should have been made for Mrs A's care in the event of a deterioration, which should also have been explicit about what to do if new stroke deficits were detected.

Both advisers said the nursing staff did not monitor Mrs A appropriately or observe her every two hours, as required. The medical adviser said that the scoring system used by staff to monitor Mrs A (the Glasgow Coma Scale or GCS) was not entirely suitable. The nursing adviser said that not taking Mrs A's vital signs for a period of over five hours was a serious failing. We upheld Mrs C's complaints and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• feed back the failings identified regarding the clot buster rtPA, the ABCD2 score, carotid Doppler and admission to an acute stroke unit to the staff involved;
• identify and address training needs for staff in A&E and the MAU on guideline 108 of the Scottish Intercollegiate Guidelines Network;
• provide Mrs C and her family with a written apology for the failings identified in the first recommendation;
• feed back the failings identified in Mrs A's nursing care to the staff involved;
• complete their review of the use of the GCS score, taking into consideration the medical adviser's views, and provide us with evidence of the outcome of the review; and
• provide Mrs C and her family with a written apology for the failings identified.