Source · SPSO (Scottish Public Services Ombudsman)

Ayrshire and Arran NHS Board

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201808821 Sector Health Category clinical treatment / diagnosis Decided 01 October 2020

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Full decision

Summary

C complained about the care and treatment the board provided to their late spouse (A) at University Hospital Crosshouse (UHC). A suffered a heart attack and was taken by ambulance to a hospital in another health board area. Following treatment, A was transferred to UHC, but then suffered what was thought to be a stroke event and died a week later.

C complained about several aspects of A's care, including that staff did not tell them what was happening with A and failed to advise them that A was in a coma. C also said that A's health had improved at the other hospital and they understood that A was being moved to UHC to recuperate before being sent home, but A died shortly after their arrival at UHC.

We took independent advice on the case from two advisers - a consultant cardiologist (a doctor that specialises in diseases and abnormalities of the heart) and from a nurse. We found that the medical records showed staff gave C regular updates about A's condition and tried to be realistic about the likely outcome, while being supportive of C. We considered that there was evidence that staff kept C reasonably updated about A's condition during the admission. However, we welcomed the board's apology that the communication did not meet C's needs; this showed a sensitivity to the responsibility for ongoing learning and improvement to ensure communication is tailored to the needs of individuals and their families. We found that there was a lack of clarity from the other hospital about A's prognosis and future treatment plan at the time of their transfer to UHC, which may have contributed to C's confusion and distress at this time. We included some feedback to the board about this. However, we noted that this did not influence A's care at UHC, following the sudden stroke that they suffered soon after transfer, which was ultimately fatal. We considered that, overall, A's care and treatment at UHC was reasonable and we did not uphold the complaint.

Related reading

View Decision Report 201808821 as a PDF (24.74 KB) Updated: October 21, 2020

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