Decision Report 201507514

Summary

Mr C complained about the board following the death of his partner (Mrs A). Mrs A had attended A&E at Galloway Community Hospital with abdominal pain. She was recorded to have a high temperature and fast heart rate. The doctor who examined Mrs A diagnosed her as having a urine infection, and he discharged her with antibiotics. The next day, Mrs A was accompanying a friend to a hospital in another board area when she collapsed. She developed signs of sepsis (blood poisoning), originating in the gall bladder, and despite resuscitation and intensive care, she passed away.

In their response to Mr C's complaint, the board accepted that the early signs of sepsis had been missed at Mrs A's initial attendance at A&E and apologised for this. However, Mr C brought his complaint to us as he wanted further assurances that appropriate steps had been taken to avoid similar mistakes in the future.

We took independent advice from a medical adviser, who considered Mrs A's initial diagnosis when she attended A&E to be unreasonable based on her symptoms at the time. We also found Mrs A's elevated heart rate and temperature to be of sufficient concern that further investigation should have been warranted and admission to hospital considered. As such, we upheld the complaint.

In response to our enquiries, the board provided extensive details of procedural changes and training that had taken place in Galloway Community Hospital to aid in the diagnosis and treatment of sepsis, so we did not consider that any recommendations of this kind were necessary. We did, however, make a recommendation regarding the doctor who assessed Mrs A, and we asked the board to apologise to Mr C.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified; and
• confirm that the doctor who assessed Mrs A has discussed the treatment they provided to Mrs A at their annual appraisal.