The patient, who had a cognitive impairment, was in Falkirk Community Hospital when they gained access to washing-up detergent that had been mistakenly left out in the staff kitchen area.
When they later became unwell, hospital staff contacted the out-of-hours GP service before the patient was transferred to Forth Valley Royal Hospital, where their condition deteriorated and they died the following week.
A complaint was later made by a relative to NHS Forth Valley about the care their late parent had received at the community hospital.
However, when the significant adverse event review (SAER) ordered by the health board failed to conclude with any certainty whether the detergent had been swallowed or contributed to the patient’s death, the relative then contacted the Scottish Public Services Ombudsman (SPSO).
The relative, only described as C in the findings published at the end of last year, complained about inaccuracies and inconsistencies in the SAER and clinical records, and also about timescales surrounding the complaint processes.
After taking independent clinical advice from a nursing adviser and a GP adviser, SPSO determined it was not possible from the evidence available and advice obtained to confirm whether the patient, identified as A, had ingested detergent.
They found the review to be “open, transparent and evidence-based”, however noted there were “inconsistencies and inadequacies in the records”.
The SPSO also found that the review did not do enough to look at the actions of the out-of-hours GP.
The report stated: “The initial advice given by the GP was to monitor A, when the observations should have prompted medical review. The GP assumed these observations were incorrect. When the GP later advised transfer to hospital, this was left to nursing staff to arrange and clear advice was not provided surrounding the urgency of the ambulance request. We found that the GP deviated from standard practice and failed to provide appropriate care to A."
The transfer from the community hospital to FVRH was also not formally documented and there was a delay in staff completing both an incident report after the detergent incident and the SAER.
There were also delays in responding to the relative’s complaint.
All of the complaints were upheld by the ombudsman.
NHS Forth Valley were told to apologise to the patient’s family for all the “unreasonable” delays, failings in the system and failure to provide appropriate care to A.
The health board was also told to ensure there are clear systems in place to investigate significant adverse events and complaints.
The report also said the board should ensure the out-of-ours service has clear protocols in place for escalations to hospital for medical review, while GPs should act with due care when receiving second hand clinical information.
A spokesperson for NHS Forth Valley said: “We have apologised to the family and can confirm that NHS Forth Valley has taken action to address all of the recommendations highlighted in the report. We have also made a number of additional changes to further improve our arrangements for carrying out clinical reviews and strengthen our documents management and record keeping systems.”