NHS Grampian has been told to provide further training for its staff and apologise to the spouse of a patient who died after losing a large amount of blood during a kidney dialysis treatment.
The Scottish Public Services Ombudsman (SPSO) also found that the health board did not investigate the complaint originally made by the spouse “appropriately or adequately” – and did not provide them with all the information they needed for their own investigation until “several inquiries” had been made.
The complaint revolved around the care received by a patient – referred to as ‘A’ within the report – while they were being treated at Aberdeen Royal Infirmary.
After being admitted to the hospital with symptoms of kidney failure, A started dialysis treatment using an arteriovenous fistula that had been formed previously.
A fistula involves surgery to join an artery to a vein, resulting in a ‘tougher’ vein which enables medics to insert a needle three times a week for dialysis.
Three days after A’s admittance and the subsequent start of their treatment, they started to lose blood from the needle insertion site.
Unable to control the bleeding, staff sought assistance from the vascular surgery team, whose work stitching the affected vessel stopped further loss – but A’s condition continued to deteriorate, and they died at 8pm that evening.
Death was ‘entirely preventable’
To help investigate what went wrong at the hospital, the SPSO sought advice from a consultant nephrologist, who pointed to the patient’s prescription for blood thinner warfarin and their use of aspirin, which can affect clotting.
Among “a number of failings” identified in the ombudsman’s report were the confusion around a recent dose change in warfarin, which led to A being given more than they were prescribed by their GP, and the insufficient monitoring of a measure used to determine the effect of blood clotters.
The SPSO found that these “errors” were significant in causing A’s “profound bleeding and death”.
The report adds: “Other warning signs, which may or may not have contributed to A’s death, were not noticed and considered by the medical team. The lack of escalation of A’s blood loss meant that time was lost before clinical staff attended.”
It continues: “We found that staff did not have a clear escalation policy of when and whom to call when they were unable to control the bleeding.
“These deficiencies in care contributed to A’s death, which we found was entirely preventable.”
Complaint handling criticised
The report was also critical of the way the health board investigated the original complaint made by A’s spouse – referred to as ‘C’ – who accused staff in the dialysis room of not seeking assistance quickly enough, and said there was a delay in stitching A’s arm.
This complaint was ultimately upheld by the SPSO, who said the patient’s care and treatment “fell below a reasonable standard”.
The ombudsman added that their investigation process was “impeded” by NHS Grampian not supplying records until after a draft report had been sent to them, and said some information that should have been gathered during the health board’s inquiry was only collected after they started their own.
Board asked to apologise and improve
The SPSO told the board to “apologise to C for the failings in A’s care and treatment”, and to improve staff training and awareness of subjects such as warfarin monitoring and what to do in the event of a fistula bleed.
They also asked for improvements in the handling of complaints.
NHS Grampian must provide the ombudsman with a record of the apology and evidence that measures have been taken to ensure deaths of this nature do not happen again.
A spokeswoman for the health board said: “We have accepted the ombudsman’s findings in the case.
“It is clear that we did not provide the level of service we aspire to, either during care of A or during investigation of C’s complaint.
“We will be in direct contact with C to provide an apology and would also take this opportunity to apologise publicly.”
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