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Decision Report 201708572

  • Case ref:
    201708572
  • Date:
    August 2018
  • Body:
    Orkney NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    admission / discharge / transfer procedures

Summary

Mrs C, who works for an advocacy and support service, complained to us on behalf of her client (Mrs B) about the care and treatment Mrs B's late father (Mr A) received from the board.

Mr A requested medical assistance at his home as he was feeling breathless and asthmatic. An advanced nurse practitioner (ANP) attended Mr A in the early hours of the morning. After carrying out an assessment, the ANP concluded that Mr A's symptoms were consistent with pneumonia (an infection of the lungs). The ANP provided treatment and advised Mr A to visit the health centre later that day for further review.

When Mr A presented at the health centre, his condition was noted to have worsened and he was subsequently referred to hospital. On arrival at the hospital Mr A suffered a cardiac arrest and died.

Mrs C complained that the board unreasonably delayed in referring Mr A to hospital and that they should have requested an air ambulance rather than travel by ferry and road.

We took independent advice from a GP adviser. We found that the ANP carried out a thorough assessment of Mr A's symptoms and that his diagnosis was appropriate. We found that it was not clinically indicated that an earlier referral to hospital was required. We also considered that the board's decision to transfer Mr A by ambulance on the ferry was safer and faster than an air ambulance. We did not uphold Mrs C's complaints.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Amendment - 22/08/2018

Please note that the original version of this decision summary (published 22/08/2018) included the line "We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set".

This line was included in error, and we apologise for this. There were no recommendations made on this case and, as such, we are not seeking evidence of any action from the Board.

Updated: December 2, 2018