Scottish Public Services Ombudsman

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  • Case ref:
    201601389
  • Date:
    July 2017
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
    Health
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Some upheld, recommendations

Summary

Mrs C complained to us about the care and treatment her late mother (Mrs A) had received at Biggart Hospital and University Hospital Ayr. Mrs C said that staff at Biggart Hospital had failed to treat her mother's deteriorating condition. We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that there had been prompt recognition of Mrs A's deteriorating condition and that the care and treatment provided to her had been reasonable. We did not uphold this aspect of Mrs C's complaint.

During her treatment Mrs A was transferred from Biggart Hospital to University Hospital Ayr. She was subsequently transferred back to Biggart Hospital. Mrs C complained about the decision to transfer Mrs A back to Biggart Hospital given that she had tested positive for sepsis, MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) and E.coli (bacteria found in the digestive system). We found that Mrs A's condition had improved at the time to the point that it was reasonable to consider her transfer back to Biggart Hospital. We did not uphold this aspect of the complaint.

Mrs C also complained that the communication between Biggart Hospital and University Hospital Ayr was unreasonable. We found that there was no clear documentation of communication between the hospitals about the fact that Mrs A had E.coli and MRSA. We therefore upheld this aspect of the complaint.

Mrs C further complained that Biggart Hospital had prescribed her mother a form of morphine, despite the fact that Mrs A had previously had an adverse reaction to morphine. We found that Mrs A's allergies, drug intolerances and drug interactions could have been better documented, and we made a recommendation in relation to this. However, we found that it had been reasonable to give Mrs A small doses of morphine, as the effect on her was being monitored. We did not uphold this complaint.

Finally, Mrs C complained about the medication Mrs A received at University Hospital Ayr. We found that it had been reasonable to try alternative medications given that Mrs A was able to tolerate them. In addition, nursing staff had observed Mrs A for adverse side effects. That said, Mrs A had not been given her routine medication when she was admitted to University Hospital Ayr and the reasons for this had not been adequately recorded. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for the lack of clear documentation and communication.
  • What we said should change to put things right in future:
  • The policy on communication between hospitals regarding patient transfer should be reviewed.
  • The computer system for recording allergy information should be reviewed.
  • A review policy around prescribing medication on admission, including who is responsible for this if the admitting team are too busy, should be produced.
  • We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Download case 201601389 as a PDF (15.91 KB)

Updated: July 19, 2017