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Decision Report 201709020

  • Case ref:
  • Date:
    July 2020
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


C complained to us that the board had unreasonably given their child (A) an overdose of morphine. We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that A had received an overdose of morphine as a result of a doctor failing to discard excess morphine from a syringe and giving them the full syringe. We upheld this aspect of the complaint.

C also complained that the board then failed to carry out observations on A appropriately after the error was identified. We found that staff had recognised the need for close observation, but the observations were not clearly documented in A's clinical records and we were unable to say definitively whether or not the observations were carried out appropriately. Therefore, we upheld this aspect of the complaint.

Finally, C complained that the board had failed to provide a reasonable response to their complaint. We found that there had been an unreasonable delay in responding to the complaint. Also, there was no evidence that the board had kept C updated during this time. We upheld this aspect of the complaint.

We noted that the board had already apologised for these failings but we made further recommendations for learning and improvement.


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

  • The board should review their guidelines for administration of intravenous medication in light of the findings of this investigation and ensure there are explicit instructions on how to deal with situations where only part of the prepared dose is to be administered.
  • Patient monitoring and observations should be appropriately recorded in the medical records.

In relation to complaints handling, we recommended:

  • Where an investigation takes longer than 20 working days, the board should inform the complainant, agree revised time limits, and keep them updated on progress.

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.

Updated: July 22, 2020