Apology over Western General Hospital tragedy

Published on Friday 24 October 2008 10:17

HEALTH bosses have apologised to the family of a man who died following "shortcomings" in the care he received.

The 64-year-old, known only as "Mr C," died of a heart attack at the Western General Hospital in 2006.

He had been admitted four days earlier when his condition worsened following bowel surgery.

After a complaint to the Scottish Public Services Ombudsman, a number of issues were probed at the hospital's high dependency ward.

The ombudsman upheld a complaint from the man's wife that the levels of care he received were below a reasonable standard and that her initial complaint was not dealt with effectively by NHS Lothian. However, it stopped short of blaming the man's death on the failings of the hospital.

Libby Campbell, associate director of nursing for NHS Lothian, said: "We would like to take this opportunity to apologise once again to the family of Mr C for the distress caused.

"We accept the recommendations in the report and have already taken several steps to prevent a repeat of similar incidents.

"Since this incident two years ago, we have carried out a robust review of patient monitoring.

"Nursing staff have also been given enhanced training in working with and managing critical intravenous feeding and medicine tubes."

She added: "We also intend to hold workshops to improve communications between our staff and patients."

The ombudsman's report noted that records had not been properly kept in the run-up to Mr C's death, making it difficult for nurses to keep track of medication.

It also highlighted a leaking insulin tube, which was designed for treating the man's diabetes but was, in fact, only succeeding in making his gown wet.

When the error was noticed, a nurse arrived with milk and a biscuit to increase the man's sugar levels.

The ombudsman said that while this was normal practice, it was not anything like as much of a boost as Mr C required.

The ombudsman's report concluded: "The advisers were clear that one could not say whether Mr C's death was avoidable.

"For example, one could not say that the issues with the leaking central line led to his death.

"However, they said the health board should not ignore the possibility of a link between the significant upset to Mr C's metabolism and, a few hours later, his cardiac arrest."

The ombudsman's report also criticised low staffing levels but noted that the senior charge nurse on duty that night has since left and drastic improvements have been made.