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Case ref:201507505
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Date:June 2016
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the clinical treatment and nursing care that her late mother (Mrs A) received at the Glasgow Royal Infirmary. Mrs A was admitted after becoming unwell at home and it was suspected that she was suffering from gallstones blocking the bile duct. Mrs A had a number of existing conditions and had been prescribed clopidogrel (a drug that reduces blood clotting) for one of these conditions.
As Mrs A was on clopidogrel, which increases the risk of serious bleeding during invasive tests, it was decided that a scan would be carried out to investigate. This confirmed that she had a blockage in the bile duct and it was agreed that an endoscope (a thin flexible tube) procedure would be arranged to investigate further and clear the blockage. Mrs A's clopidogrel had been stopped the previous day due to other test results and so arrangements were made for the endoscope procedure to take place in six days' time. Mrs A's condition deteriorated a few days later and she developed sepsis (blood poisoning) before the procedure could be carried out. She was transferred to the high dependency unit but passed away.
After taking independent advice from an adviser who is a consultant surgeon, we did not uphold Mrs C's complaint about clinical treatment. The adviser considered that appropriate investigations had been carried out and that while having the endoscope procedure earlier might have avoided sepsis developing, it was reasonable practice to have waited until the clopidogrel had been stopped for a period of seven days before undertaking the procedure. The adviser also considered that the drug had been stopped at a reasonable point in Mrs A's admission.
After taking independent advice from a nursing adviser, we did not uphold Mrs C's complaint about nursing as no failings in care were identified.