Decision Report 202303554

Summary

C complained that the board unreasonably failed to provide appropriate care and treatment to their late parent (A). A attended A&E with an injured arm after a fall at home. A was treated and sent home but was admitted to hospital a few days later with low sodium and anaemia. A was discharged after a short stay but re-attended A&E a few days later. An abdominal x-ray showed dilated loops of bowel and blood tests taken showed acute kidney injury. A’s condition deteriorated and they died later that day.

We took independent advice from a consultant in emergency medicine and a consultant geriatrician (specialist in medicine of the elderly). In relation to A's first admission, we found that the management of A’s sodium levels was reasonable. However, there was a lack of accurate charting of A’s bowel movements. We also found that medications to address A’s constipation were not provided at discharge. Therefore, we concluded that the care and treatment with respect to A’s constipation was unreasonable and upheld this part of C's complaint.

C also complained that the board failed to provide A with appropriate care and treatment during their second attendance at A&E. We found that there was an unreasonable delay in A being seen by a doctor on arrival. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in the investigation. This should also include the apologies that were included in the correspondence to our office in response to our enquiries. 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:

• Bowel charts should be routinely and accurately completed for patients admitted to hospital. Patients should receive appropriate treatment including assessment and relevant examinations to assess known symptoms.
• Patients should receive appropriate treatment including triage and medical assessment in accordance with their symptoms, when attending A&E. The board should have appropriate staffing to allow timely assessment and treatment of patients in A&E, and escalation plans to address instances where patient numbers become unmanageable. The board should have an escalation plan for instances where overcrowding / patient numbers reach critical levels.

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.