NHS Highland bosses ordered to apologise to family of woman who died suddenly at Raigmore Hospital
The public services ombudsman heard concerns raised by a nurse about a patient at Raigmore Hospital were not acted on before she died.
Shona Ann Macleod, from Inverness, passed away on July 27, 2017 from a lung condition after being admitted to the hospital earlier the same day.
A staff nurse correctly diagnosed a pulmonary embolism a few hours before she died, but doctors in charge of her care overlooked the nurse’s concerns.
More than 700 people attended Miss Macleod’s funeral at Smithton Culloden Free Church, where she was described as a “ray of sunshine”.
A former pupil of Cradlehall Primary School and Culloden Academy, Ms Macleod was born with Down’s syndrome and campaigned for children with incontinence to be better accommodated at school while a pupil herself.
She was also involved in a wide range of sporting activities through Highland Disability Sports and became a successful Taekwon-do competitor.
After her death her father Donald Macleod complained to the Scottish Public Services Ombudsman (SPSO) about his daughter’s care. He believed she may have lived if the nurse had been listened to.
This week, the SPSO ruled in Mr Macleod’s favour.
Hospital bosses have been told to apologise and to make changes in the way staff raise concerns about clinical practice.
The SPSO said that Ms Macleod was “forced to wait an unreasonable amount of time for an x-ray”. This in turn led to a failure in diagnosis, and subsequently her death.
The report went on: “Ms Macleod suffered from a rare autoimmune disease, vasculitus, and was admitted to hospital with symptoms of diarrhoea and vomiting, headaches and abdominal pain.
“She experienced episodes of coughing up blood while in hospital and died later that day.
“We noted a member of the nursing staff appeared to identify the possibility of a pulmonary haemorrhage, and whilst this was communicated to the doctor, it was not acted upon.”
The NHS Highland board has been told to raise awareness of vasculitus and pulmonary haemorrhage among staff, and to “ensure all staff feel they can raise concerns with a senior member of staff if they consider their concerns are not being addressed”.
Speaking after the report was published, Mr Macleod said: “Shona Ann was loved and cared for by many people, and she loved and cared for people in return. She was a remarkable young woman who lived life to the full and tested all the boundaries. She lived life with a joyfulness and enriched the lives of so many of the people she came across. We all learned so much from her.
“I am looking forward to seeing how these vital recommendations will be implemented throughout Raigmore and NHS Highland as a whole. It is critical that the culture in NHS Highland enables all members of staff to raise concerns as quickly as is necessary with a senior member of staff if they consider that their initial concerns about the health and care of a patient are not being adequately addressed.
“I am grateful to the SPSO for the quality of the investigation they carried out and the deeply considerate ways in which they engaged with me.”
An NHS Highland spokeswoman said it had apologised to the family, adding: “We accept the findings of the SPSO and steps are being taken to ensure we meet the recommendations.”