Decision Report 201400354

Summary

Mr C's father (Mr A) had a complex medical history and was admitted to Aberdeen Royal Infirmary with a suspected heart attack, which was believed to have been caused by an infection in his leg. Surgery to amputate his leg below the knee was delayed to minimise post-operative risks, but carried out two months later. A few weeks after surgery, Mr A's health began to deteriorate, but there was a delay in admitting him to the intensive care unit and he died of a cardiac arrest. Mr C complained that staff failed to provide a reasonable standard of medical and nursing care and treatment, and that there was a failure to admit Mr A to the intensive care unit within a reasonable time. Mr C also complained about the length of time it took the board to respond fully to his complaint.

We took independent advice from a nursing adviser and an adviser who is a specialist in end-of-life care. We found that the medical and nursing treatment provided was reasonable and that there was relatively prompt recognition of Mr A's problems. However, we also found that the delay in admitting Mr A to the intensive care unit was unacceptable. We found that, while it may not have altered the outcome for Mr A, an earlier admittance would have improved his chances of survival. Also, while the board's investigation of the complaint was thorough and comprehensive, the delay in responding was unreasonable, as it caused further distress to Mr C and his family at a difficult time.

Recommendations

We recommended that the board:

• ensure the action plan is implemented in full;
• review their processes to ensure that investigations into complex complaints are completed within a reasonable time and that complainants are regularly updated and told of their right to contact us; and
• apologise for the failures in complaints handling this investigation identified.