Source · SPSO (Scottish Public Services Ombudsman)

Greater Glasgow and Clyde NHS Board - Acute Services Division

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201708292 Sector Health Category clinical treatment / diagnosis Decided 01 February 2019

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Full decision

Summary

Mr C complained to us about the care and treatment Miss A had received in the Queen Elizabeth University Hospital after she was admitted with axillary cellulitis (a bacterial skin infection around the armpit). The cellulitis increased over the next day and Miss A was eventually taken to theatre to have the damaged tissue removed.

We took independent advice from a consultant general and vascular surgeon (a  specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels). We found that there had been a delay in carrying out a scan when Miss A was admitted to the hospital. If an early X-ray had been carried out, the gas in the tissues would have indicated the severity of the infection and prompted immediate intervention. We considered that this delay possibly led to Miss A needing to have more tissue removed to control the infection. We upheld this aspect of Mr C's complaint. However, we were satisfied that the board had apologised for this and had taken reasonable action in response to the matter.

Mr C also complained that Miss A had been kept on blood thinning medication for too long a period. Miss A had been prescribed the medication because she had previously had clots. The medication was increased in hospital after a CT scan showed a further clot. We found that it had been reasonable to keep Miss  A on blood thinning medication while she was in hospital, as she was immobile. We did not uphold this aspect of the complaint.

Miss A's blood thinning medication was then stopped after she developed a haematoma (a mass of blood). Miss A was subsequently discharged from hospital and died at home after suffering a pulmonary thromboembolism (a  blocked blood vessel in the lungs). Mr C felt that the appropriate blood thinning medication would have prevented this and complained that it was stopped rather than reduced after Miss A developed the haematoma. We found that it had been reasonable to stop the medication in view of the haematoma. We did not uphold this aspect of the complaint.

Related reading

View Decision Report 201708292 as a PDF (24.35 KB) Updated: February 20, 2019

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