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Case ref:201701404
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Date:May 2018
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Body:Shetland NHS Board
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) at Gilbert Bain Hospital. Mrs A had pancreatic cancer and when she was admitted to hospital she could not eat. She was later assessed for palliative surgery (surgery which provides relief, but not a cure) at a different hospital, and was ultimately unable to have this surgery. Mr B felt that the reason his wife could not undergo the surgery was because she was not given adequate nutritional support (the giving of nutrients, either intravenously (directly into a vein) or by drip feeding through a tube placed in the digestive system) at Gilbert Bain Hospital.
We took independent advice from a consultant physician. We found that it was reasonable not to give Mrs A nutritional support until a decision was made to assess her for palliative surgery at the second hospital. Therefore, we did not uphold the complaint. However, we found that there were discussions between the two hospitals that were not recorded, so we made a recommendation to address this.
Recommendations
What we said should change to put things right in future:
- Medical staff should maintain records of verbal conversations with staff at other hospitals in the medical records.
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.