The complainant (C) complained to my office about the care and treatment provided to their late grandparent (A) by Lanarkshire NHS Board (the Board).

A arrived at the Emergency Department of University Hospital Monklands by ambulance in the afternoon of 11 June 2022 and was admitted to hospital in the early hours of 12 June 2022. 

While in hospital, A’s condition deteriorated. Over the course of the evening of 12 June 2022, A became seriously unwell. A vomited, developed abdominal pain, and had a distended abdomen. A received abdominal x-rays and input from the surgical team, and staff attempted to stabilise A.

A small bowel obstruction (narrowing or blockage in the bowel, which usually requires urgent treatment) was identified in the early hours of 13 June 2022. Sadly, A died a short time later.

C complained to me (having been though the Board’s complaint process) about the events preceding A’s death. In particular, C complained about events relating to the assessment of A on admission and that communication with A’s family prior to A’s death was unreasonable. 

The Board reviewed this case again after receiving notification of my investigation and identified some areas for improvement. They determined that further investigation through a Significant Adverse Event Review (SAER) was not required. 

During my investigation I took independent advice from a Consultant in Acute and General Medicine. Having considered and accepted the advice I received, I found that:

Care and treatment

• An abdominal x-ray should have been carried out when A was admitted to hospital in the early hours of 12 June 2022 on the basis of A’s presentation and also as part of an assessment for Clostridium difficile (C. diff, an infectious disease) as set out under relevant national prescribing guidelines. 
• It was unreasonable that there was no record of an abdominal examination by a consultant on the morning of 12 June 2022 given an abdominal examination should have been carried out and documented based on A’s presentation.
• The Board’s failure to carry out an abdominal x-ray on admission and the lack of evidence that an abdominal examination was carried out by the consultant on the morning of 12 June 2022 means that the opportunity to detect signs of bowel obstruction was missed at an earlier stage when A was stable enough to undergo life-saving treatment. Therefore, there is a prospect that A might have survived.

Communication

• On balance, I found that the Board’s communication with A’s family was reasonable.

Taking all of the above into account, I upheld C’s complaint about A’s care and treatment. I did not uphold C’s complaint about the Board’s communication. 

I was also critical that a SAER was not held in this case given it related to an unexpected death and given the Board’s review had identified three specific points where consideration should be given to escalating to a SAER.

Finally, I found the Board’s handling of C’s complaint was unreasonable.

Further comment

It is of concern to me that I have made similar findings regarding Health Boards not carrying out adverse event reviews in other recent public reports (case references 202100979; 202209575; 202100560; 202101928; 202105840; 202200588). I intend to write to the Scottish Government and Health Improvement Scotland to draw their attention to the findings and recommendations I have made in relation to adverse event reviews in recent cases, including this one.

Recommendations

The Ombudsman’s recommendations are set out below:

What we are asking the Board to do for C:

We are asking the Board to improve the way they do things:

We are asking the Board to improve their complaints handling:

Evidence of action already taken

The Board told me they had already taken action to address the issues and provided me with an action log which I am satisfied are reasonable. I will ask them to confirm that all actions are now complete and for an explanation about how they will assess their effectiveness going forward. (By 16 April 2025)

Feedback 

Points to note

In the advice I took (and accepted), the Adviser said that:

1. the Emergency Department Nursing Record (which recorded a history of diarrhoea and vomiting) provided very useful additional information that - had it been used - may have guided the team towards earlier investigation and management; 
2. the record made by a junior doctor who admitted A to the MAU included a picture of a hexagon to signify the abdomen, with an arrow through it, to indicate everything was fine. The Adviser said this record is not detailed, does not address bowel sounds and does not record what the doctor found, only showing that nothing was abnormal. The Adviser said that, while not unreasonable, this is a concern; and
3. A should have been nursed in a side room until potentially infective diarrhoea or vomiting was excluded.

I am drawing these points to the Board’s attention and encourage them to consider and reflect on them, and whether there is scope for further learning from them.

The complainant (C) complained to my office about the care and treatment provided to their late adult child (A) by Lothian NHS Board – Acute Division (the Board). 

A was in their thirties and suffered from a number of chronic illnesses and very poor health. A had regular admissions to hospital and received treatment from community and district nurses between admissions to hospital. 

A was admitted to the Royal Infirmary of Edinburgh (the hospital) on 6 June 2021 with shortness of breath. A’s pre-existing leg wounds were treated in hospital during their admissions. A was discharged home on 24 June 2021. A continued to receive treatment at home from district nurses for their leg wounds. 

A’s condition deteriorated and they were admitted to hospital again on 26 August 2021. A’s health continued to deteriorate, and A underwent a right knee amputation on 2 September 2021. A did not make a full recovery following surgery. A remained in hospital and suffered a cardiac arrest on 11 October 2021. Sadly, A died the same day. 

C complained that A’s wounds were not appropriately assessed or treated during their admission to hospital, or during the time they were cared for at home. 

In their complaint response the Board said that throughout A’s care, where infection was suspected by the district nursing team, appropriate treatment was provided. During the course of treatment at home by district nurses, A’s care plan was reviewed regularly, changes were made to the wound care plan when necessary, dressings were changed when appropriate and a referral made to the tissue viability service. 

In response to our enquiries the Board said that there was evidence of good practice during A’s admission to hospital in June 2021 with respect to the management of A’s wounds. The Board acknowledged a wound care chart was not completed on the day of admission, but there were clear entries thereafter evidencing A’s wound care. 

With respect to A’s admission to hospital in August 2021, the Board said that A’s wound care was appropriately documented and that available records evidenced appropriate nursing care during A’s admission. 

During my investigation I took independent advice from a registered nurse. Having considered and accepted the advice I received, I found that:

Care at home

• There was no evidence of appropriate wound assessments having been undertaken whilst A was treated by district nurses for their wounds.
• The choice of dressings was on occasion unreasonable and inappropriate to manage A’s wounds.
• Whilst there were occasions where the frequency of dressing changes was stepped-up to daily changes, these were inconsistent. As a result A was left with wet and foul smelling dressings, which is unreasonable.
• There was an unreasonable delay in seeking specialist wound care when it was clear A’s wounds were deteriorating. 

Care during hospital admissions

• During both admissions A’s wounds were not appropriately assessed and there were a number of instances of inappropriate and unreasonable wound care provided to A.
• During A’s June 2021 admission to hospital there was an unreasonable failure to update their wound management plan and appropriately assess a deep abscess.
• During the admission from August 2021, inadine dressings were inappropriately prescribed and applied.
• Negative Pressure Wound Therapy (NPWT, a device to promote wound healing) was used on A’s wounds without evidence of the appropriate assessments having been carried out prior to its use. NPWT was applied in circumstances where it was contraindicated. Its use was unreasonable.
• Clinicians and nursing staff did not appear to have the requisite knowledge in relation to the application of NPWT. 

Taking all of the above into account, I upheld C’s complaints

Recommendations

What we are asking Lothian NHS Board - Acute Division to do for the complainant

What we are asking Lothian NHS Board - Acute Division to improve the way they do things

Feedback

Points to note

The ‘house held’ records which contain the written record of care provided at A’s home have been reported as lost. I encourage the Board to reflect on the circumstances leading to their loss, and whether there is any learning for them in relation to record keeping and records management policies and staff guidance.