Health board apologises for woman's death at Dr Gray's Hospital
AN investigation into a woman's death at Dr Gray's Hospital has concluded with a public apology from NHS Grampian.
The woman's sister complained about the care and treatment provided, claiming there had been an unreasonable delay in diagnosing her condition.
The Scottish Public Services Ombudsman has now upheld that complaint.
Ms A, as she was referred to in the ombudsman's report, attended the emergency department in the hospital after striking her head.
She had suffered a cut which was glued shut, and then discharged.
The following day she was admitted to the hospital with a high heart rate and shortness of breath.
It was subsequently noted that Ms A was suffering from acute chronic kidney injury and chronic atrial fibrillation– a heart condition that causes an irregular and often abnormally fast heart rate.
She became unresponsive and was taken for a CT scan to check if her head injury was contributing to her loss of consciousness.
Ms A died in the radiology department.
The ombudsman's report said: "We took independent advice from an emergency medicine adviser and a consultant in acute medicine.
"We found that the standard of documentation for Ms A's presentation to the emergency department was poor.
"It was also unreasonable that she was not scanned in the emergency department before she was discharged, given her reduced level of consciousness and confusion; her headache; and the fact that she was on anticoagulant medication (medication to prevent blood clots).
"Further tests should have been carried out and her discharge from the emergency department was contrary to guidance.
"In addition, the advice given to her when she was discharged from the emergency department would have been challenging for Ms A to understand and retain.
"It was also surprising that, when she was admitted to hospital, Ms A was given increasing doses of beta-blockers given that she had an allergy.
"Therefore, we upheld this aspect of the complaint. The board said that they have taken action to address these failings and we have asked them to provide evidence of this."
The report did not uphold another complaint by the sister – referred to as Ms C – that NHS Grampian had failed to provide an accurate account of Ms A's death.
"We found that the board's response on this matter had been accurate."
Ms C also complained that the board failed to communicate appropriately with her family.
The report said: "We found that it had been unreasonable for the board not to contact the next of kin when Ms A deteriorated.
"We upheld this aspect of the complaint. However, we noted that the board had acknowledged and apologised for this failure and we made no further recommendations in relation to this."
NHS Grampian issued a public following the publication of the report.
Its statement said: "We have accepted the Ombudsman's decision and recommendations in this case. The care we provided was not what it should have been.
"We have apologised to Ms C and would also take this opportunity to apologise publicly."