Scottish Public Services Ombudsman

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  • Report number:
  • Date:
    December 2014
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Keywords:
    Diagnosis, clinical treatment, nursing care, complaints handling

The complainant (Mr C) raised concerns about the treatment his late daughter (Ms A) received from Ayrshire and Arran NHS Board (the Board).  Ms A had attended University Hospital Crosshouse (the Hospital)'s Emergency Department and was admitted, but sadly passed away a couple of days later.  Mr C complained to my office about the clinical and nursing care his daughter had received and also the Board's handling of the complaint he and his wife (Mrs C) made to them.

Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:

  • take appropriate steps to assess and treat Ms A's sepsis (upheld);
  • provide appropriate nursing care for Ms A (upheld); and
  • handle Mr C's complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • review their protocols for identification of sepsis, identification of deteriorating patients and sepsis management and audit their performance using the Scottish Patient Safety Programme;
  • reduce the time to consultant review for on-call teams managing critical illness, in line with the relevant Royal College of Physicians' Guidance;
  • improve access to intensive care advice for on-call clinical teams;
  • use this case in educational / mortality review meetings in the emergency department and medical units;
  • ensure this case will be included in the consultants' next appraisal;
  • carry out a Significant Event Analysis, with reflective commentary, of the care and treatment provided to Ms A and the handling of Mr and Mrs C's complaint; and
  • apologise to Mr and Mrs C in writing for the failings identified in this report.

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201303932 as a PDF (88.44 KB)

Updated: December 19, 2014