Hospital told to apologise over man's death

HEALTH chiefs were today told to apologise to a woman for "serious failings" in the treatment of her son who died alone at home four days after being released from hospital.

The Scottish Public Services Ombudsman Jim Martin upheld a complaint from the dead man's mother that the standards of care received fell beneath the expected level.

The 27-year-old, who weighed 27.5 stones and had a history of drink and drug abuse, was admitted to the Victoria Infirmary in Glasgow in May 2007 after being referred by his GP with a number of symptoms, including a sore throat, cough, shortness of breath and facial swelling.

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He was sent home the next day but died suddenly four days later.

A post-mortem examination revealed he had heart disease and also found evidence of heart failure. The cause of death was recorded as being cardiac enlargement due to obesity.

After considering the case, the Ombudsman recommended that Greater Glasgow and Clyde NHS Board apologise to the man's mother, only identified as Mrs C, for "the serious failings" identified in his report.

He also urged the health board to reflect on the medical lessons to be learned from this case.

The Ombudsman described the case as being "very difficult and sensitive".

His report said doctors did not make a clear diagnosis when the patient, identified only as Mr A, was in hospital and he was discharged with plans for an outpatient abdominal ultrasound scan.

But an expert adviser told the Ombudsman that abnormalities in an ECG (electrocardiogram) and chest x-ray "certainly suggested there was a cardiac cause".

The adviser, a consultant cardiologist, said: "The evidence in the records is that these abnormalities were not recognised by the clinicians treating him and indeed there is no evidence that there were reviewed at the consultants' review.

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"Had they been, I believe that further inpatient investigation of his heart would have been organised."

The Ombudsman said both this adviser and another had told him there were "several clues to the presence of heart disease".

He said: "In their view, these clues were either overlooked or misinterpreted, largely because of the fact that obesity and alleged alcohol overuse were blamed, or that the evaluation of Mr A was not sufficiently rigorous to detect them at the time of his admission."

In his report, the Ombudsman added: "The error in this case was one of omission, in that the board did not review and comment at senior level on the chest x-ray and ECG."

However, he said that even if this had been done, "the outcome might have been the same".

The Ombudsman also upheld a complaint that the board's responses when the dead man's mother sought an explanation for her son's death were "poor".

The report said Greater Glasgow and Clyde NHS Board had accepted the recommendations made and would act on them.