Decision Report 202308827

Summary

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them.

The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Internal reviews should include a thorough consideration of all of the relevant evidence including clinical records and there should be reflection on these in an open and transparent manner in order that lessons can be learned.
• Overdoses complicated with seizure activity and aspiration lower respiratory tract infection may require observation over and above the advice provided by Toxbase. Patients admitted with overdoses and who present with a history of seizure activity should be admitted for a minimum of 24 hours observation. Concerns raised by relative(s) of patients should be listened to by staff.