Decision Report 201507866

Summary

Mrs C complained to us that the board had failed to provide reasonable care and treatment to her son (Mr A) when he attended the Royal Alexandra Hospital after taking an overdose of prescribed medication. Mr A was discharged from the hospital later the same day. Mr A had continuing symptoms of nausea and was given medication to prevent nausea and vomiting. He died two days later. This is thought to have been due to the effects of the overdose he took before attending hospital.

We took independent advice from a consultant in emergency medicine. They found that the level of medication taken by Mr A fell into the range that could cause death and required careful medical assessment and close observation. They noted that staff in the hospital ought to have contacted the National Poisons Information Service to discuss the matter, particularly as Mr A had taken a multi-drug overdose. We considered that the information service would have advised that Mr A should not be discharged until he was free of symptoms, as death can occur up to 54 hours after ingestion of the prescribed medication. Mr A was not free of symptoms as he required medication to control his vomiting.

Although we could not say whether Mr A would have survived had appropriate action had been taken, his symptoms could have been managed better had he remained in hospital. We therefore upheld Mrs C's complaint. However, we were satisfied that the board had learned lessons from the failures in Mr A's care and that the action they had taken in response to these failings was reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings in her son's care.