NHS Tayside has been rapped by Scotland’s public services watchdog after they found their treatment of a patient who later died from a blood clot “fell below a reasonable standard”.
The Scottish Public Services Ombudsman (SPSO) found failings in the care of the patient, referred to as ‘A’, after a complaint was raised by a family member.
Patient A had initially been admitted to hospital before being moved to a mental health facility. However, they were subsequently transferred to an acute hospital for treatment after developing “abdominal symptoms”.
Surgery had been considered for the patient but this was changed to treatment with medication.
They were transferred back to the mental heath facility but later became unwell again. The patient was then taken to A&E but died from a pulmonary embolism – a blood clot that blocks and stops blood flow to an artery in the lung.
Family felt personal care was neglected
Following their death, a family member of patient A – referred to in the SPSO report as ‘C’ – raised a complaint with the watchdog.
They said A’s dignity has been compromised because of the care administered to them. C also complained that their personal care had been neglected, and they did not receive the medication they required.
The report added: “C believed that A’s death was caused by a failure to examine A properly or ensure that A received anti-clotting medication.
“C felt that this resulted in A developing deep vein thrombosis (DVT, a blood clot in a vein) which led directly to their death.”
Concerns were also raised over the response of the NHS Tayside board to the complaint.
During their investigation, the watchdog took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly) and found a series of failings in the patient’s care.
These were:
- A’s nursing and medical care had fallen below a reasonable standard
- The board failed to communicate reasonably with C and their family
- The board could not provide evidence that they had taken the actions promised to the family following the board’s complaint investigation
- The board’s Significant Adverse Event Review had been delayed, reducing the utility of it to the board.
Concluding their report, the SPSO set out a series of recommendations “to put things right in the future”.
This included discussing the case with the medical staff involved at their next appraisal, developing clear guidance to ensure patients with mental health issues can have timely access to nursing staff trained in mental health care, and ensuing patient documentation is completed to an appropriate standard.
NHS Tayside apology
A NHS Tayside spokesperson said: “We are sincerely sorry that treatment and care in this case fell below the standard we would expect.
“We have met with the family and apologised directly to them. Our thoughts remain with them.
“We accept all the recommendations made in the report and an action plan is in place to meet the recommendations within the agreed timescales.”
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