Decision Report 202003576

Summary

C complained about the treatment which their late partner (A) received when they attended A&E at University Hospital Ayr. C was concerned about A's colour as they had an alcohol problem, but A was discharged by a doctor who said that an in-patient stay was not required. C felt that A should have been admitted for further assessment or treatment. C took A to their doctor a few days later as A continued to show symptoms, and they said the GP was also concerned that A had not been admitted to hospital. A died ten days after the A&E attendance and C felt that had staff taken appropriate action then A would have been more comfortable in the final stages of their life.

We took independent professional advice from a consultant in emergency medicine. We found that there were a number of failings identified at the A&E attendance which included a failure to establish the cause of A's bleeding and what their blood coagulation (clotting) status was. There were also failings in record-keeping and communication. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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:

• Staff should ensure that a full investigation is carried out in regards to a patient's reported symptoms and that record-keeping and communication are completed to the required standards.

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.