Decision report 201100011

Summary
Mr C had several complaints about the care and treatment received by his late mother (Mrs A) in 2008 and 2010.

We upheld Mr C's complaint about the care she received in 2008. Mr C's mother had been admitted for acute pulmonary oedema (fluid in the lungs), and as part of her treatment, an arterial line (a thin tube) had been inserted into her arm so her blood pressure could be monitored. Swelling developed around the line which was then removed, and a pseudo-aneurysm (a collection of blood under the skin from a leak in an artery) developed. We found no errors in relation to the way the line had been inserted, and our medical adviser said that a pseudo-aneurysm is a recognised complication of the use of an arterial line. However, because clear records were not kept of the management of this complication and as Mrs A had moved between units during this time, the cause of the swelling was not properly identified at first. There was also a failure to conduct a prompt medical review of the event.

Mr C was also concerned that when Mrs A had a scan of her abdomen, she had to drink a large quantity of liquid. He felt that, as Mrs A had fluid retention problems, this caused her to collapse in the scanner. We found no evidence to suggest that intake of the fluid caused his mother to collapse. We also found that the scan and giving the fluid in preparation for it were appropriate clinical treatments in the circumstances. However, we were critical that fluid balance charts were not completed for Mrs A at this time, considering her complex fluid management situation. We made recommendations to address these failings.

We did not uphold Mr C's complaint that a doctor had inappropriately noted Mrs A as a 'do not resuscitate' patient without the family knowing about this. We found that a doctor can make this decision without consultation with a patient or their family, in circumstances when resuscitation is considered ineffective. We noted that it is good practice to discuss such a decision when appropriate, and found evidence that such discussions had taken place with Mr C.

We did not uphold Mr C's complaint about Mrs A's care in 2010. We found that the use of intravenous (administered into the vein) antibiotics had been appropriate, even when giving regard to Mrs A's fluid retention problems. This was because she had a severe infection, and other clinical issues indicated that intravenous antibiotics were an appropriate method of treatment. Although Mr C was also concerned that Mrs A had difficulty passing urine, which he felt was not adequately recognised or treated, we found that this was due to kidney failure, rather than because of any clinical mismanagement.

Recommendations
We recommended that the board:
• provide evidence to the Ombudsman that staff within the hospital have received training for the care of arterial lines and the complications that can occur, including the need for prompt medical review of any complication;
• undertake an audit of record-keeping within the hospital to ensure medical records are completed timeously and comprehensively, including for patients who are moved between units within the hospital; and
• provide evidence to the Ombudsman to demonstrate that staff in the hospital are aware of the importance of completing fluid balance charts for patients with complex fluid management requirements.