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Decision Report 201806264

  • Case ref:
    201806264
  • Date:
    November 2019
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by Queen Elizabeth University Hospital and by Gartnavel General Hospital. After Mrs A died, amyloidosis disease (a condition caused by the accumulation and deposition of amyloid protein in the body in various organisations) was diagnosed. Mrs C complained that, had this condition been diagnosed earlier, Mrs A would not have suffered as she did and that she would not have been subjected to unnecessary physiotherapy or to a one-night hospital transfer which she believes exacerbated Mrs A's condition. Mrs C also complained that the board wrongly discharged her mother on one occasion and failed to admit her to a high dependency unit, but sent her to a rehabilitation unit instead.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that the medical investigations, treatment, physiotherapy and nursing care provided to Mrs A were reasonable. We did not uphold these aspects of the complaint.

However, we concluded that the decision to discharge Mrs A home from hospital on one occasion was unreasonable; the decision to admit Mrs A for rehabilitation was not appropriate due to her frailty; and the decision to transfer her to a general hospital was not reasonable. Therefore, we upheld these aspects of the complaints.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for the failure to discuss other possible options for Mrs A’s discharge and for transferring her inappropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • Before transferring or discharging frail patients consideration should be given to all the options for discharge/ transfer; whether a patient’s condition is stable enough for any transfer and whether a patient’s condition is such that they will benefit from rehabilitation if appropriate.

Updated: November 20, 2019