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Case ref:202002557
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Date:November 2021
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Body:Ayrshire and Arran 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 on behalf of their parent (A) about their care and treatment at University Hospital Ayr. A was admitted to hospital after an episode where they had become unresponsive. C raised concerns that medical staff decided to change A's epilepsy medication without getting specialist input.
We took independent advice from a specialist in geriatric (medicine of the elderly) and general medicine. We found that A had not been properly assessed, that there was no clear reason for changing their epilepsy medication and that there was a lack of communication with their family about the change. We upheld C's complaint. We considered that the board had not appropriately responded to C's complaint, so we also made a complaints handling recommendation to address that.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the failings identified in A's care and treatment and for not adequately addressing their complaint. 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:
- In an emergency setting, patients' medications for specialist conditions should normally only be changed if their diagnosis is clear, the change is unequivocally beneficial and the reasons for the change are discussed with them and/or their families/carers.
In relation to complaints handling, we recommended:
- Complaints should be responded to accurately and as comprehensively as possible, particularly when we have requested that a specific matter is addressed.
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.