A tragic patient who was rushed to an NHS Ayrshire & Arran hospital with a perforated bowel and kidney failure was given “very high doses of morphine” and ‘denied’ the opportunity of early palliative care.
And medical staff “should have checked” the medication prescribed to see if it was “working,” and “review or prescribe something else,” according to findings from the Scottish Public Services Ombudsman (SPSO).
Details of the case were outlined by the NHS watchdog, who partially upheld aspects of a complaint made against NHS Ayrshire & Arran.
The details of the patient, known only as ‘A,’ have been withheld due to confidentiality. Their spouse is only known as ‘C.’
In their report the SPSO said: “C complained about the care and treatment provided to their spouse when they became unwell with severe lower abdominal pain and vomiting.
“A was visited and examined by an out-of-hours GP, who administered an injection for vomiting and left medication.”
The patient’s condition worsened and a different out of hours GP attended the same evening.
The patient was taken to hospital and found to have a perforated bowel and kidney failure.
According to the SPSO, medical intervention was “not considered appropriate” and A’s care was redirected to palliative care.
The patient died in hospital two days later.
The SPSO report goes on: “C complained that the first OOH GP missed important aspects of A’s condition during their home visit.
“C further complained that when A was admitted to hospital, A was left in pain and discomfort for hours. It was only when C raised concerns that A was given stronger pain relief.”
The SPSO took independent advice from a GP adviser, as well as a registered nurse and a general physician in acute medicine.
Their report said: “Overall, the assessment and examination carried out by the first OOH GP was reasonable and appropriate.
“It was determined that there was nothing suggestive of an acute abdomen which would have necessitated admission to hospital. We did not uphold this aspect of C’s complaint."
C also complained that A was given "unreasonable care and treatment" in hospital, in relation to managing A’s pain.
The SPSO said: "Overall, the approach to A’s pain management by nursing staff was reasonable. Nursing staff identified A’s level of pain from first admission and throughout and took appropriate action.
“However, we found that, given the very high doses of morphine administered, medical staff should have checked the medication prescribed to see if it was working, and review or prescribe something else.
“Furthermore, given the medical team would have been aware that A was on the ward round for comfort care, a palliative care referral could have been made earlier.
“An earlier referral may have supported better comfort care for A in the final stages of life. We upheld this aspect of C’s complaint.”
Joanne Edwards, Director of Acute Services at NHS Ayrshire & Arran said: “I am sorry that we did not meet the high standards of care we strive for in NHS Ayrshire & Arran for this patient, and offer my deepest condolences to their family.
“In cases like this we always accept the recommendations in the Scottish Public Services Ombudsman (SPSO) report, address the issues highlighted and make the appropriate changes.”
Don't miss the latest Ayrshire headlines – sign up to our free daily newsletter here
