Decision Report 202406274

Summary

C complained about the care and treatment of their adult child (A) following A’s admission to hospital. A had a long standing, complex medical history including two kidney transplants and kidney cancer, and A died during their admission. In particular, C complained about A being prescribed Dapsone for a skin infection without discussion with A’s Renal Consultant and also that the Respiratory Team did not review A in the days prior to A’s death. C also complained that the board had failed to communicate in a reasonable way, in that critical information relating to A’s care had not been passed on between clinical teams or shared with the family.

The board said that A’s renal disease did not contraindicate Dapsone which was frequently used following renal transplantation. The progressive respiratory reaction which A suffered would be a very rare side effect. The board said that Dapsone was appropriately discussed with A and prescribed, with no known lung or kidney-related risks in standard guidance. The Renal Consultant was informed and raised no concerns. The board acknowledged that the communication between clinical teams as documented in the medical records was open to interpretation and that this aspect of the complaint could have been better addressed in the formal complaint response.

We took independent advice from a Renal Consultant and a Respiratory Consultant. We found that the clinical care and treatment was reasonable, and in keeping with normal practice. There was no requirement to seek advice from A’s Renal Consultant about the prescription, but they were aware of it and had no concerns. The side effect that A experienced is extremely rare such that the effect and outcome could not have been foreseen. We found that the Respiratory Team were appropriately involved where required and that the care provided was reasonable. We did not uphold this complaint.

However, we found that the board had failed to communicate in a reasonable way and that communication fell short of a reasonable standard in relation to the involvement of the Respiratory Team. We also found that there were complaint handling failings. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings in communication. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

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

• Clinicians should clearly and consistently communicate to patients and their families, as appropriate, the roles of different teams and relevant clinicians involved. If staff agree to arrange review from another team this should be followed up to ensure it happens, or an explanation given as to why this is not necessary.
• Where an adverse drug reaction causes or contributes to a death, this should be reported to COPFS in line with their guidance.
• Serious adverse medicine reactions should be reported in line with the Yellow Card Scheme guidance.

In relation to complaints handling, we recommended:

• Where failings are clear from the evidence available, organisations should openly acknowledge and apologise for these. The board should ensure that complaint responses are accurate and based on the available evidence and relevant guidance. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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.