Summary
Mrs C complained about the care and treatment her late husband (Mr C) received at Raigmore Hospital after he attended the Emergency Department (ED) by ambulance. Despite Mr C being initially diagnosed with a chest infection, his condition deteriorated suddenly and he died the following day. Mrs C questioned whether her husband was given appropriate treatment and complained that staff did not properly communicate with her.
When the board investigated Mrs C's complaint, they did not identify any failings in relation to the treatment provided to Mr C, although they acknowledged that staff could have communicated better with Mrs C.
We took independent advice from a consultant in emergency medicine and a consultant cardiothoracic anaesthetist. We were concerned about significant failings the emergency medicine consultant adviser identified in relation to the treatment Mr C received whilst in the ED, including the fact that the board's local investigation of the complaint did not pick these up. We accept that the treatment in the ED led to Mr C's abrupt and unexpected deterioration.
Whilst we found that the care provided in the Intensive Treatment Unit (ITU) was of a reasonable standard, we were critical of the communication with Mrs C about her husband's continuing deterioration. We found that Mrs C had been waiting for a significant period of time in a side room in the ED when ITU staff were trying to contact her and that this was likely the result of poor documentation and communication by ED staff.
Redress and Recommendations
The Ombudsman recommends that the Board:
- conduct a Significant Event Analysis (SEA) into the care Mr C received in the ED in order to identify appropriate improvements in clinical practice and share these findings with the family and my office;
- ensure that the findings of this investigation and the outcome of the SEA are shared with the doctors involved in Mr C's care in the ED and discussed at their next appraisal for shared learning and improvement in clinical practice;
- conduct a review of the complaint in order to explore how the complaints handling failed to identify these issues;
- provide documentary evidence showing the steps that have been taken to improve triage record-keeping;
- apologise to Mrs C and the family for the failings this investigation has identified; and
- share these findings with relevant staff who had been involved in Mr C's care to highlight the importance of documenting conversations with relatives to ensure effective communication between hospital wards.