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Case ref:201404925
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Date:May 2016
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Body:Lanarkshire NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C's wife (Mrs C) had a complex medical history and had been diagnosed with asthma, bronchiectasis (a long-term condition where the airways of the lungs become abnormally widened leading to a build-up of excess mucus) and frequent pneumonia. Mrs C struggled to recover between bouts of illness and she understood from healthcare professionals that she had emphysema (lung disease). In October 2013, Mrs C was told that investigations had shown mild abnormalities and that she did not have emphysema. Mr C said that his wife was very distressed at this.
Mrs C was admitted to Monklands Hospital two months later with respiratory problems. Her condition deteriorated significantly and she died several weeks after admission with sepsis (blood infection), heart failure and bronchiectasis. Mr C complained about the provision of medical and nursing care and treatment to Mrs C, and about the board's complaints handling.
We took independent advice from medical and nursing advisers. We found that the medical and nursing care and treatment provided to Mrs C was reasonable. However, at one of the out-patient appointments, the discussion about Mrs C's diagnosis was significant but there was no record of this and no comment on Mr C's understanding of the diagnosis and so, on balance, we upheld this complaint. In relation to record-keeping, we were satisfied that the board had responded to the complaint in a reasonable way.
Recommendations
We recommended that the board:
- bring the record-keeping failing and the medical adviser's comments to the attention of relevant staff; and
- apologise for the failings identified.