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Forth Valley NHS Board

  • Report no:
  • Date:
    August 2016
  • Body:
    Forth Valley NHS Board
  • Sector:

Mr A, who suffered from schizophrenia (a long-term mental health condition that causes a range of different psychological symptoms), was admitted to the Clinical Assessment Unit (CAU) at Forth Valley Royal Hospital (the hospital).  Mr A had been suffering from a sore throat, a cough and a wheeze in his chest.

Mr A was treated for an infection and the possibility was raised that he may have chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed).  The day after his admittance, Mr A was reviewed and was transferred to a medical ward.  Mr A died the following morning.

Mr A's mother (Mrs C) complained that Mr A did not receive reasonable care and treatment and that the board failed to take into account his lack of capacity to understand how ill he was.  She also complained that the standard of record-keeping was not adequate and that she was not able to obtain accurate information from staff about what had happened to her son.  In addition, she complained that she was given unclear information about whether a SAE (significant adverse event) investigation by the board into Mr A's death would be carried out.

As part of my investigation, I obtained independent advice from a senior doctor with experience in acute medicine (adviser 1) and a nursing adviser (adviser 2). I also considered the board's own investigation of the complaint.

The board acknowledged that it was unacceptable that Mr A's observations were not carried out four hourly after his transfer to the medical ward and apologised for this failing.  However , adviser 1 said that there were failings in relation to Mr A's care and treatment throughout his admission to the hospital.  Adviser 1 said that in a patient with type 2 respiratory failure (which Mr A had), the measurement of arterial blood gases (ABGs) to provide information regarding the amount of carbon dioxide in the blood stream and the acid-base status of the patient was important.  Adviser 1 said that Mr A's ABGs should have been rechecked and despite the deterioration in the ABGs there was no plan or comment in the medical records.  In addition, Mr A was not reviewed by a consultant from the respiratory team.

Adviser 1 added that, while it was reasonable that Mr A received treatment for an exacerbation of COPD, other diagnoses should have been considered and treatment for this should have been part of Mr A's management plan.

While the board said that Mr A was deemed to be in a stable position, adviser 1 said that on admission and throughout his admission to hospital he was significantly unwell.

Adviser 2 also indicated that the nursing care Mr A received fell below the standard expected of a patient with a recognised respiratory condition.

I was concerned that, given Mr A's past medical history and in view of his refusal of treatment during his admission to the hospital and that he left the hospital against medical advice, a formal assessment of his mental capacity to understand the seriousness of his illness and ability to make informed decisions was not carried out.

Both advisers said that there was a lack of recognition of the seriousness of Mr A's condition by nursing and medical staff. They said he was not seen by a consultant until over 24 hours after his admission and was not seen again by a senior clinician prior to his death.  I am critical of the failings which meant, that potentially, the opportunity to recognise and treat Mr A was missed.

The board also accepted that there were failings in relation to record-keeping and had taken action as a result of these failings.  However, I am concerned that there appear to be conflicting reports of how Mr A spent his final hours. I consider that this would have added to Mrs C’s and the family’s distress at a very difficult time. I am also concerned that the advice I received, and accept, is that the lack of prescription of oxygen on Mr A's chart was not in accordance with guidance and that the miscalculation which occurred in relation to the national early warning score (NEWS) was in the view of adviser 1 a serious issue.

While the board explained why they decided that an SAE investigation would not be carried out, adviser 1 said that in this case there were issues around the recognition of an acutely ill patient, assessment of mental capacity and escalation and treatment of Mr A's type 2 respiratory failure and that an SAE investigation should have taken place.  Adviser 1 was of the view that there were serious lessons to be learned from this case which needed to be acted on by the board.

Redress and recommendations
The Ombudsman recommends that the board:

  • apologise for the failings identified in this complaint;
  • bring adviser 1's comments about the frequency of the ABG measurements to the attention of relevant staff and report back on action taken;
  • take steps to ensure that, when patients with a known history of mental health problems are formally assessed for capacity, a recognised clinical assessment instrument is used, or alternatively an opinion is sought from the psychiatry service;
  • take steps to ensure all patients admitted acutely are reviewed within the timeframe recommended by the Royal College of Physicians;
  • take steps to ensure that timely escalation of acutely unwell patients with acidotic type 2 respiratory failure occurs and they are reviewed in person by either a respiratory physician or other clinician with appropriate knowledge and experience;
  • bring the failures identified in relation to Mr A's prescription chart and the miscalculation of the NEWS to the attention of relevant staff and ensure they are addressed as part of their annual appraisal;
  • carry out an audit of NEWS charts to ensure the documentation is accurate and report back to this office;
  • consider the current education and training in place for the care of vulnerable adults in acute care and take any appropriate steps to meet any gaps identified and report back on action taken;
  • provide a copy of the completed nursing review referred to at paragraph 43;
  • in view of adviser 1's comments, carry out a reflective SAE investigation of this case and provide this office with a copy; and
  • review their current significant adverse incident guidance in light of adviser's 1's comments detailed in this report.


Updated: December 11, 2018