Decision Report 202003264

Summary

C complained about treatment provided by the board to their spouse (A) who was initially admitted to University Hospital Monklands with a fractured leg before being transferred to Wishaw General Hospital for further management. A's condition subsequently deteriorated, in response to which they received a full dose of Tinzaparin (anticoagulant). As A showed no improvement, they underwent an exploratory laparotomy (a surgical incision into the abdominal cavity, for diagnosis or in preparation for major surgery). A few hours later, due to further deterioration, A underwent a further laparotomy. During this procedure, significant bleeding and an injury to A's spleen was identified. A splenectomy (a surgical operation involving removal of the spleen) was then performed. A's condition did not improve and they died shortly after.

We firstly obtained advice from a consultant orthopaedic (conditions involving the musculoskeletal system) surgeon. We found no failings in relation to the orthopaedic care provided to A. We then obtained advice from a consultant general surgeon. We found that while it could not be definitively said how the tear to the spleen identified at the second laparotomy had been caused, it was possible that this may have been caused some time between commencing closure of the abdomen at first laparotomy and the second laparotomy. However, we also noted that A should not have received a full dose of Tinzaparin before it was established whether they would need surgery, as this was irreversible and greatly increased the risk of bleeding during surgery. The surgical adviser told us that the dose of Tinzaparin administered prior to surgery intensified the bleeding caused by the injury to A's spleen and contributed to A's death, although they may still have died from the underlying cause of their acute illness that could not be identified during post mortem examination. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably administering a full dose of injectable Tinzaparin to A before establishing whether they would require a laparotomy to explore the cause of their abdominal pain and deterioration. 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:

• Clinical staff should be aware that full-dose injectable anticoagulation should be withheld until it is clear that the patient does not require an operation due to the bleeding risk. In the event, a pulmonary embolism or deep vein thrombosis is identified.

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.