Decision Report 202309413

Summary

C complained about the standard of medical care and treatment provided to their late partner (A) by the board in relation to their risk and diagnosis of liver cirrhosis (permanent scarring of the liver which leads to dysfunction) and gastrointestinal haemorrhage.

A was initially under the care of the board’s rheumatology service for psoriatic arthritis, which was treated with medication. The board’s gastroenterology service then began to care for A, and, after testing, found that A had liver cirrhosis with portal hypertension (elevated blood pressure in the portal vein).

After several months, A’s condition began to deteriorate and they attended the medical ambulatory care unit and A&E within a few weeks. A was discharged home both times. A died two days after their contact with A&E.

We took independent advice from four advisers who are consultants in rheumatology, gastroenterology, general medical and emergency medicine. We found that the standard of rheumatology, general medical and emergency medicine was reasonable. However, we found that the standard of gastroenterology was not reasonable in that A’s signs of deterioration were not taken seriously enough by the gastroenterology service including that the signs of abnormalities were not reasonably investigated, that A’s portal hypertension should have been identified following an endoscopy and that A should have been referred to a liver transplant unit. We found that the multidisciplinary team meetings unreasonably failed to pick up A’s clear deterioration and arrange appropriate investigations and treatment, and discussions were brief and decisions were deferred. We found that keeping A in the specialist nurse led clinic when they were diagnosed with liver cirrhosis and portal hypertension, and deemed suitable for a transplant, was unreasonable. Finally, we found that there were record keeping failings including clinic letters that failed to contain important information about A’s diagnosis and condition and we found that an urgent referral for a gastroscopy should have been considered sooner. 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 investigation in relation to the standard of medical care and treatment. 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:

• Patients with liver disease should be managed and receive treatment in line with the relevant guidelines. Additionally, patients with advanced liver disease should have a clear management plan and be reviewed by a consultant or medical staff when their condition deteriorates. Nurse led clinics should have a clear protocol on when to refer patients for a consultant or medical review. Finally, Multidisciplinary team meetings should have sufficient time to review patients and blood results over time, and further investigations, treatment etc. should be acted on fully and within a reasonable time. This includes referrals to liver transplant unit within a reasonable time.

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.