Test result overlooked in case of woman who died days after hospital discharge

21 December 2017, 15:05

Monklands Hospital

A health board has been ordered to apologise over the care of an elderly woman who died two days after she was sent home from hospital, after doctors overlooked an abnormal blood test.

The 78-year-old, referred to only as Mrs C, was sent home alone in a taxi at 2am from Monklands Hospital in Airdrie, North Lanarkshire, without her family being informed.

The woman had been taken by ambulance to the hospital on May 2 2016 because of abdominal pain.

Her medical history included high blood pressure, pulmonary hypertension, a cardiac pacemaker and previous major abdominal surgery.

Two doctors examined her with a junior member of the hospital's surgical team and believed gastroenteritis was the problem.

She was discharged within an hour of checks but died at home on May 5. A post-mortem found the main cause of death to be ischaemic and valvular heart disease.

The Scottish public services ombudsman (Spso) was asked to investigate the case and found a "significantly abnormal" blood test result had been overlooked and that she had not been offered pain relief.

Investigators said: "Had a more senior doctor overseen Mrs C's care, and due attention been given to this test result, she would have been admitted to hospital which may have avoided her death."

Her husband said he found his wife "knocking at the door, distressed and in pain" in her night clothes when she was dropped off in a taxi.

The ombudsman said it was "critical, even shocked" by the way the patient was discharged without any of her family being informed.

The report said: "In terms of Mrs C being discharged home during the early hours of the morning, we considered this unreasonable given Mrs C was an elderly, frail woman with multiple health problems.

"We were critical that hospital staff did not communicate with Mr C about the discharge and that the paperwork which prompts such discussions had not been completed appropriately.

"We upheld both complaints and made a number of recommendations to address the issues identified. The Board have accepted the recommendations."

Spso called on NHS Lanarkshire to apologise to Mr C in writing and to ensure that more senior doctors saw patients like Mrs C before being discharged.

Dr Jane Burns, NHS Lanarkshire acute divisional medical director, said: "We regret any instance where we fail to provide the highest standards of care for our patients and we will contact the complainant directly to offer our sincere apologies for the failings identified in the report.

"We have fully accepted the recommendations within the Ombudsman's report and will develop an action plan to address them.

"The lessons learned will be shared to help avoid similar occurrences in future."