NHS board ordered to apologise after patient became ‘critically unwell' with sepsis due to 'inadequate care'

A health board has been ordered to apologise to a patient after they became “critically unwell” following breast surgery as a result of “inadequate care”.

The Scottish Public Services Ombudsman (SPSO) has instructed the NHS board, which has not been identified, to apologise to the patient, referred to as “A” to protect their anonymity.

The complaint was logged by an anonymous support and advocacy worker referred to as “C” throughout the report.

A had undergone breast surgery to remove nodes and C complained that the board did not adequately assess and manage A’s wound when it showed signs of infection.

The wound deteriorated and A became critically unwell with sepsis.

The board carried out a Significant Adverse Event Review (SAER), in which A expected greater involvement.

C also complained that the SAER failed to identify that the incident met the Duty of Candour threshold and did not address the key issue, which was the inadequate care provided.

The board responded to the complaint stating the staff involved used their clinical judgement to assess the wound, which did not show signs of infection.

They added it was difficult to investigate the adequacy of the wound assessment due to the omission of notes they made.

The board acknowledged communication between health care professionals was impeded by a reliance on a paper-based system and the clinical record keeping was inadequate.

The board further advised the SAER was a formal process, which did not allow for A’s inclusion and maintained the incident did not meet the Duty of Candour threshold.

They considered the SAER to be adequate, as an investigation had taken place that had identified a number of learning points and recommendations.

After an investigation the SPSO upheld the complaint filed on behalf of patient A.

The watchdog found the wound assessment to be inadequate, leading to a missed opportunity for appropriate wound management and that those involved in A’s care lacked knowledge of current best practice in terms of wound assessment.

The SPSO also also found the SAER to be inadequate as it failed to address the key issues of wound assessment, wound management and antimicrobial stewardship and failed to identify the incident met the Duty of Candour threshold.