NHS Highland rapped over patient’s diagnosis and care
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NHS Highland board has apologised to a family about a parent’s treatment after an unidentified hospital in the area failed to diagnose a clot in the lung.
Their complaint to the Scottish Public Services Ombudsman (SPSO) was upheld.
The SPSO found that medics failed to diagnose that the parent, called A in the report, was suffering from a pulmonary embolism (PE) after being admitted to hospital via A&E.
Staff failed to take an X-ray when it should have been done due to “communications failings”, and delayed starting antibiotics to treat suspected pneumonia.
The ombudsman’s report stated: “We considered that if these delays did not happen, it is likely that A would not have needed to be admitted to a high dependency unit for care.”
The delay likely led to A’s condition worsening.
A daughter or son, referred to as C, complained on behalf of their parent (A), who had oesophageal cancer at the time of the complaint, claiming that the care and treatment was unreasonable.
C was concerned also that A had been incorrectly treated as a palliative patient when their cancer was not advanced, and should not have impacted on the care received.
The SPSO also identified failings in the board’s handling of the complaint.
The ombudsman stated: “The board’s response did not address the matters raised in a structured format, which made it difficult to follow.”
The SPSO asked the organisation to apologise for the failings.
To ensure things are put right in future, the SPSO says a “suitable handover tool” should be used consistently to ensure instructions have been carried out as prescribed.
The report said: “In relation to complaints handling, we recommended complaint responses should be clear and understandable, in line with the NHS complaints handling procedure.
“We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.”
An NHS Highland spokeswoman said: “We accept the findings of the report in full and have apologised for the failures identified.
“We will be re-examining this case to ensure that the learning is widespread among our clinical staff.
“We have also introduced new measures to improve our complaint responses. These include a group of consultants having the opportunity to review responses to ensure they make sense from a medical perspective as well as senior clinicians meeting more families to answer their questions which has been very useful in feeding back to the wider clinical team about how our care has affected some of our patients.”
