Source · SPSO (Scottish Public Services Ombudsman)

Tayside NHS Board

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201305105 Sector Health Category clinical treatment / diagnosis Decided 01 May 2015

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Full decision

Summary

Mr C complained about care and treatment provided to his daughter (Miss A) at Perth Royal Infirmary when she attended the eye clinic there. Mr C believed that her condition was misdiagnosed, and that the treatment prescribed may have aggravated her condition and led to her sudden death.

Mr C told us that Miss A was being treated by her GP for acute conjunctivitis. The common treatment is with antibiotic (drugs to fight infection) drops or ointment and in some cases also steroid (drugs to fight inflammation) drops or ointment. The GP prescribed an antibiotic only. When her condition worsened, Miss A went back to the GP and was referred urgently to the eye clinic. Miss A attended the clinic the following day and a specialist doctor there diagnosed marginal keratitis (MK - an eye condition), with a possible allergic reaction to the antibiotic prescribed by the GP. The specialist changed the antibiotic, added a steroid and arranged a follow-up appointment for a week later. Three days later, however, Miss A died suddenly. Mr C told us that he disagreed with the stated cause of her death. He was of the view that she had in fact been suffering from a more serious infective eye condition and that the treatment provided was not only wrong, but contributed to her death by increasing pressure and inflammation in the brain.

Our investigation included taking independent advice from one of our medical advisers, who was of the view that appropriate examinations and investigations were carried out and that Miss A had been correctly diagnosed with, and treated for, MK. The adviser said that although the two conditions have similar symptoms, sufferers of the more serious condition also experience other symptoms, which Miss A did not have. The adviser was, therefore, of the view that Miss A's diagnosis, care and treatment were reasonable, appropriate and timely and there was no evidence that these contributed to her sudden death.

Amendment to summary text When it was originally published on 20 May 2015, the first sentence of the second paragraph read: Miss A was being treated by her GP for marginal keratitis (MK- an eye condition).

This has been amended to read: Mr C told us that Miss A was being treated by her GP for acute conjunctivitis.

The reference to ‘MK’ in the fifth line of the second paragraph has been amended to read marginal keratitis (MK – an eye condition) .

4 June 2015

Related reading

View Decision Report 201305105 as a PDF (67.28 KB) Updated: March 13, 2018

View original on SPSO (Scottish Publ… website

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