Decision Report 201500624

Summary

Mr A, who had a history of type 1 diabetes, chronic kidney disease and who had had a leg amputated, was admitted to Dumfries and Galloway Royal Infirmary in November 2013. He was complaining of chest pain, a shortage of breath and had an ulcerated toe. After admission, Mr A continued to be unwell and a week later, he had a cardiac arrest and died. His sister (Mrs C) complained that board staff failed to do enough for him or to recognise that he was a very sick patient. She also complained about the way in which her formal complaint was subsequently handled.

We took independent advice from a consultant geriatrician with an accreditation in general medicine and from a senior nurse. We found that Mr A's condition was a complex one and that doctors had treated him reasonably in terms of his symptoms and there were no reasonable precautions that could have been taken which could have prevented his death with certainty. We also found that the nursing care given to Mr A had been reasonable, although we identified some failure and shortcomings in record-keeping. We did not uphold Mrs C's complaints about care and treatment. However, we found that Mrs C's complaint had been dealt with badly. It did not initially progress through the complaints process and was beset by delay and confusion. Even when the board identified that this had happened, Mrs C was sent an inadequate reply. For these reasons, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• remind the nursing staff involved in Mr A's care of their responsibility to keep appropriately detailed records;
• make a full apology for the delay and confusion in dealing with Mrs C's complaint; and
• ensure that they provide complaint responses that are thorough and appropriate.