NHS Borders has issued an apology to a woman who was discharged from the BGH with a serious heart and lung condition, writes Andrew Keddie.
The case was referred to the Scottish Public Services Ombudsman (SPSO) by her daughter, who was dissatisfied with the treatment her mother had received.
After an investigation, the watchdog upheld the complaint, has demanded an apology and concluded staff should have been aware the patient had been diagnosed days earlier at another hospital with pulmonary emboli – blockages of the blood vessels from the heart to the lungs.
The SPSO report describes how the woman, referred to as Mrs A, was taken to the emergency department of the BGH after collapsing at home and was later transferred to another hospital, in a different NHS area, for specialist investigations.
Tests at the second hospital revealed no abnormalities in Mrs A’s pacemaker, but, after further tests, she was diagnosed with pulmonary emboli. She was prescribed the blood thinning agent warfarin and transferred back to the BGH a few days later.
The report states: “The medical transfer documentation did not include information about the new diagnosis and treatment, although the nursing transfer document specifically identified them.
“When Mrs A was readmitted to the BGH, staff only considered the medical transfer documents and missed the pulmonary emboli diagnosis.”
Despite her daughter (Mrs C) expressing concerns about her mother’s ability to cope at home, she was deemed medically fit to do so and was discharged two days later.
“Mrs A became increasingly breathless, however, and was readmitted two days later when the pulmonary emboli diagnosis was picked up and treated,” explains the report.
During its investigation, the SPSO sought advice from one of its medical advisers, a consultant physician.
“After taking independent advice, we upheld Mrs C’s complaint. The adviser considered that the failure to identify Mrs A’s diagnosis from the nursing transfer document was unreasonable and that insufficient effort was made to assess her before she was discharged.”
Responding to the decision, Evelyn Rodger, interim director of acute services, told The Southern: “NHS Borders has accepted the recommendation in the SPSO report and we have written and apologised to the patient.
“We fully recognise and regret the aspects of the patient’s treatment and complaint handling, which did not meet expected standards.
“We will take what has been learned from this experience to improve our service in the future.”