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Decision Report 201706269

  • Case ref:
  • Date:
    November 2019
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mr C complained about the care and treatment provided by the board to his child (Child A) at Royal Hospital for Children, Glasgow. Mr C also complained there was a lack of reasonable communication about Child A and that the board did not respond reasonably to his complaints. Child A had been transferred from another hospital with a history of focal seizure and decreased conscious level. They were admitted to the paediatric intensive care unit (PICU) and after a period of time transferred to a another ward. Child A was initially diagnosed with a type of encephalitis (an acute inflammation of the brain).

We took advice from a senior consultant paediatric neurologist and a senior paediatric nurse. We found that the care and treatment Child A received during their admission to the PICU was appropriate and there was no delay in considering, diagnosing and treating Child A’s condition while they were in the PICU. Child A was subsequently transferred from the PICU to another ward where they developed another type of encephalitis. While Child A received appropriate medical treatment, we raised concern that Child A was not re-admitted to PICU for closer nursing observation given their respiratory difficulties and low Glasgow Coma Scale (GCS) scores (a scoring system used to describe the level of consciousness of a patient). While this did not have an adverse effect on Child A’s short or long-term clinical outcome, we considered that their re-admission to the PICU would have allowed for closer and more appropriate nursing care and observation, and would have reduced significantly or avoided much of Child A’s family’s distress. Therefore, we upheld this aspect of the complaint.

In relation to the nursing care, we found that the nursing care including specialist nursing care which Child A received while he was in the PICU and in the ward, was reasonable. Accordingly, we did not uphold this aspect of Mr C’s complaint.

In relation to Mr C’s complaint about communication, we did not find evidence to conclude that staff failed to communicate reasonably with each other about Child A’s care and treatment or that Mr C was given conflicting advice concerning this. Overall, we found that there appeared to have been reasonable communication with Mr C and his family. However, we highlighted areas where communication with Mr C could have been improved. The board also acknowledged in their complaint response that communication with Mr C’s family could have been better when Child A was transferred to another ward for which they had apologised and taken action to address. Given the shortcomings identified in communication, on balance, we upheld this aspect of the complaint.

Mr C also complained about the board’s handling of his complaint. We considered the length of time that Mr C waited for a formal response to his original complaint to the board was excessive and that, on occasion, the board had failed to communicate reasonably with Mr C about his complaint which added to his distress. Given this, we upheld the complaint. We noted that the board had acknowledged that there were delays and had appropriately apologised to Mr C for this. The board also told us that their complaints department had put in place an agreed process of cover for staff who were on planned or unplanned leave. Taking account of this, we considered the action the board had taken was reasonable.


What we asked the organisation to do in this case:

  • Apologise to Mr C and his family for not re-admitting Child A to PICU given their clinical condition and that communication with Mr C's family about Child A's care and treatment could have been better. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • Relevant staff should review their approach to admitting patients with low GCS scores and respiratory difficulties to PICU.
  • Where a patient’s case is complex, consideration should be given to appointing senior named members of the clinical and nursing staff to communicate principally with the patient and/or their family

Updated: November 20, 2019