Source · SPSO (Scottish Public Services Ombudsman)

Highland NHS Board

SPSO (Scottish Public Services Ombudsman) Upheld Reference 201708328 Sector Health Category clinical treatment / diagnosis Decided 01 September 2019

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Full decision

Summary

Mr and Mrs C complained about the care and treatment their child (Child A) had received in Raigmore Hospital. Child A had asthma and was referred to the hospital by their GP because of breathing problems. They were admitted to the children's ward and was discharged on the following day. They were readmitted three days later and were then discharged later that day. Child A was readmitted again on the same day after a rapid deterioration in their symptoms. Their condition continued to deteriorate and the emergency team in the hospital took them to theatre. They were then transferred to the intensive therapy unit before being transferred back to the children's ward three days later.

Mr and Mrs C complained that staff had unreasonably considered that Child A had anxiety. We acknowledged that it can be difficult on occasions for both clinicians and patients to distinguish feelings of breathlessness due to asthma from those due to anxiety or a combination of both. We found that much of the care and treatment provided to Child A had been reasonable. It was reasonable to carry out spot-checks of their oxygen saturations, and their medication was also in keeping with standard asthma guidelines. However, on balance, the delay by medical staff in responding when nursing staff continued to raise concerns about Child A's condition had been unreasonable. The discharge letter was also inadequate, as it did not describe the clinical course accurately and did not give GPs and those subsequently involved in Child A's care a full picture of the issues. We upheld this complaint.

However, we did not make any recommendations, as the board had already apologised to Mr and Mrs C. They had also stressed to staff the importance of listening to patients and the importance of appropriate assessment of any child with breathing difficulties. The board also told us that in future, discharge letters would be verified by a consultant.

Related reading

View Decision Report 201708328 as a PDF (24.27 KB) Updated: September 18, 2019

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