Source · SPSO (Scottish Public Services Ombudsman)

Lanarkshire NHS Board

SPSO (Scottish Public Services Ombudsman) Upheld Reference 201404897 Sector Health Category clinical treatment / diagnosis Decided 01 July 2015

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Full decision

Summary

Mrs A, who had cancer, was admitted to Monklands Hospital as an emergency. Her daughter (Ms C) complained that although it was known that Mrs A was at risk from Deep Vein Thrombosis (DVT - a blood clot in a vein), she was not given preventative drugs. Ms C said that as a consequence, Mrs A developed DVT with bilateral emboli (blood clots on both lungs) and required painful, daily injections until her death a few months later.

We took independent advice from a consultant physician and the complaint was investigated. This showed that Mrs A had been at risk from DVT and accordingly, she should have been started on preventative medication in line with standard guidelines. Despite the board saying that their decision not to give the preventative medication was likely to have been because Mrs A was anaemic and they were concerned about blood loss, there was no record which stated this in her medical notes, nor had any alternative, mechanical methods of prevention been discussed. In light of our findings, we upheld Ms C's complaint.

Recommendations

We recommended that the board: make a formal apology in recognition of their failure to treat Mrs A appropriately; and consider incorporating printed boxes for preventative medication into their notes and drug charts - and adding a prompt to ask the doctor to annotate a reason if this was not prescribed.

Related reading

View Decision Report 201404897 as a PDF (12.73 KB) Updated: March 13, 2018

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