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Case ref:201904995
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Date:October 2020
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Body:Dumfries and Galloway NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
C complained about the care and treatment provided to their spouse (A) when A was an in-patient at Dumfries and Galloway Royal Infirmary after being transferred from another hospital. A had been commenced on Sando K (a medication used to treat and prevent low potassium levels). Three days later, A's potassium levels were found to be high. A's condition deteriorated and they were transferred to the critical care unit. C complained about the board's management of A's potassium levels and kidney function.
We took independent advice from a consultant in acute medicine. We found that that there was a failure to note A's potassium levels were normal the day after being transferred and subsequent failures to check this on the following two days. Whilst we found that it was not A's potassium levels which resulted in their admission to the high dependency unit, we considered the failings to be unreasonable and we upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C and A for the failure to provide reasonable care and treatment in relation to A's potassium levels and kidney function during their admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
What we said should change to put things right in future:
- Sando K should only be administered when required, and patients on Sando K should have daily reviews to ensure it is still required.
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.