Summary
C complained about the care and treatment their spouse (A) received while undergoing kidney dialysis in Aberdeen Royal Infirmary (the Hospital). A had progressive kidney failure, and had an arteriovenous fistula formed in anticipation of complete kidney failure. A fistula requires surgery to join an artery to a vein so that blood goes directly into the vein rather than going down to the small blood vessels of the hand before returning. If successful, the vein becomes larger and “tougher” which allows needles to be inserted three times a week to circulate blood out of the body to a dialysis machine.
A was admitted to Aberdeen Royal Infirmary with worsening symptoms attributed to severe kidney failure, with the intention of starting dialysis using the fistula. During dialysis treatment three days later, A started to lose blood from the needle insertion site. Staff attempted to control the bleeding but were unable to and sought assistance from medical staff. The vascular surgery team attended and were able to stitch the bleeding vessel, which stopped further blood loss, but A’s condition deteriorated and clinical staff were unable to stabilise them. A died of a myocardial infarction (heart attack) at 20:00 that evening. C complained that assistance was not sought quickly enough by staff working in the dialysis room. They complained that there was a delay in stitching A’s arm.
We took independent advice from a consultant nephrologist (the Adviser). The Adviser noted A’s complex medical history. They had advanced chronic kidney disease and focal segmental glomerular sclerosis (FSGS, a disease of the kidneys usually diagnosed by kidney biopsy), among other medical conditions, and were prescribed a range of medication including warfarin (an anti-coagulant, or blood thinner, used to treat or prevent blood clots) for atrial fibrillation (an abnormal or rapid heart rate, occurring when the heart’s upper and lower chambers beat out of coordination). A was also on aspirin which may increase bleeding risk by its effect on platelets, key to blood clotting.
We found a number of failings in A’s care and treatment. Medicines reconciliation on A’s admission failed to pick up a recent dose change in warfarin, resulting in A being given a higher dose than they had been prescribed by their GP. There was insufficient monitoring of International Normalised Ratio (INR, a measure of how long it takes the blood to clot used to determine the effects of anticoagulants on the clotting system). The Adviser told us that A’s admission to hospital, recent decline in functional status, elevated C-reactive protein (CRP, inflammation marker), low albumin (a protein produced by the liver that circulates in blood plasma and temperature) were all triggers for more frequent monitoring. Additionally, A was on aspirin, which in combination increases the bleeding risk.
We found that a number of individual risk factors and errors combined to cause profound bleeding and death. The confusion surrounding warfarin dosing and insufficient INR monitoring were significant in causing such extensive bleeding. Other warning signs, which may or may not have contributed to A’s death, were not noticed and considered by the medical team. The lack of escalation of A’s blood loss meant that time was lost before clinical staff attended.
Grampian NHS Board (the Board)’s response and learning focused on warfarin prescription and monitoring. We saw no evidence of changes of practice or policy regarding fistula bleeds. We found that staff did not have a clear escalation policy of when and whom to call when they were unable to control the bleeding.
These deficiencies in care contributed to A’s death, which we found was entirely preventable.
In conclusion, we found that the Board’s care and treatment fell below a reasonable standard, and we upheld C’s complaint.
We also found that the Board failed to investigate C’s complaint appropriately or adequately. It took several enquiries before the Board provided all the information we were asking for. We noted that statements of certain members of staff were obtained by the Board in response to our enquiry, rather than during the Board’s own investigation which was when we would have expected them to be taken. There were also some records which were only provided to us after the Board had received our draft report, which impeded our investigation process. All the relevant information should have been reviewed in the course of the Board’s original investigation, then provided to this office in response to our initial enquiry.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for C:
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What we found
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What the organisation should do
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What we need to see
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- The Board failed to adequately monitor A’s INR levels.
- Staff did not communicate with each other the risks associated with A’s warfarin and aspirin medication.
- There were documentation failings in respect of the dialysis.
- Clinical staff failed to note and act upon other risk factors at the time of dialysis, including raised CRP, low albumin levels and raised temperature.
- When A’s fistula started bleeding, staff failed to escalate this promptly
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Apologise to C for the failings in A’s care and treatment.
The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance
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A copy or record of the apology.
By: One month of final decision
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We are asking the Board to improve the way they do things:
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What we found
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Outcome needed
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What we need to see
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- The Board failed to adequately monitor A’s INR levels.
- Staff did not communicate with each other the risks associated with A’s warfarin and aspirin medication.
- There were documentation failings in respect of the dialysis.
- Clinical staff failed to note and act upon other risk factors at the time of dialysis, including raised CRP, low albumin levels and raised temperature.
- When A’s fistula started bleeding, staff failed to escalate this promptly
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Staff are aware of the importance of monitoring INR levels. There is a policy in place in respect of frequency of monitoring and staff should be appropriately trained and supported to apply it.
Staff are appropriately trained and so aware of the risks associated with warfarin and other medications including aspirin, in the context of blood clotting.
Dialysis documentation is thorough and includes details of all pertinent information, in particular needle size used and staff are appropriately informed of this.
Staff ensure blood test results are considered and acted upon, and are appropriately trained and supported to do this.
Staff are trained and aware of what to do in the event of a fistula bleed
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Evidence that our findings have been fed back to relevant staff in a supportive manner that encourages learning.
Evidence that the Board has taken measures to improve the clinical knowledge of the staff concerned in relation to warfarin (and other) monitoring, fistula bleeding and dialysis documentation.
By: Three months of final decision
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A’s death was a serious adverse event that was preventable
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The Board shares learning with the wider kidney community (Scottish Renal Association, Renal Association, British Renal Society)
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Evidence of the learning having been shared.
By: Three months of final decision
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We are asking the Board to improve their complaints handling:
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What we found
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Outcome needed
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What we need to see
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The Board’s complaint investigation failed to identify the significant failures in A’s care and treatment, and failed to identify adequate learning
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The Board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement
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Evidence that the findings on this complaint have been fed back in a supportive manner to the staff involved in investigating C’s complaints and that they have reflected on the findings of this investigation. (For instance, a copy of a meeting note or summary of a discussion.)
By: One month of final decision
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| The Board failed to provide all relevant information during our investigation |
All information relevant to a complaint under investigation is provided at the appropriate time |
Evidence that the Board has reflected on its responses to this office and made any necessary changes to its approach to ensure that relevant information is identified and shared timeously.
By: Three months of final decision
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