Lanarkshire patient not warned of risks of medication by hospital staff before death
NHS Lanarkshire has been ordered to apologise to the partner of a patient who died after health staff failed to warn them of medication risks.
The Scottish Public Service Ombudsman (SPSO) heard that the patient (named A in the inquiry) was initially admitted to hospital due to abdominal pain, severe lower back pain, weight loss and reduced appetite. Following a CT scan, it was found that they had a left hepatic vein thrombosis (a blood clot in the vein draining the liver).
A was given blood thinning medication (anticoagulants), however, it was found that a blood clot was found in the main vein draining into the liver and the patient was issued with a different blood thinning medication. A was later found unresponsive after complaining of a headache and vomiting.
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The ombudsman heard that they were given an anticonvulsant medication before being rushed for a CT scan, where it was found that they had extensive intracerebral haemorrhage (bleeding into the brain tissue). Staff then administered medication to reverse the effects of the blood thinners.
Scans revealed that the extent of the bleeding was not survivable and the patient died shortly after.
Their partner complained to the SPSO that the health board failed to warn of the risks of the anticoagulation medication and did not tell the family that the medication was the cause of death or include it in the death certificate.
Following advice from a consultant in acute medicine, the regulator upheld the complaint, writing: "We found that the board failed to warn A of the risks of the anticoagulation medication before commencing the treatment.
"We also found that the board unreasonably failed to include the anticoagulation medication on the death certificate and failed to communicate that it was a cause of death to A’s family. Therefore, we upheld these parts of A's complaint."
A had also raised concerns over the use of levetiracetam and protamine, however, this was found appropriate by the regulator.
The SPSO told NHS Lanarkshire to apologise to the patient's partner and identified changes to be made.
It continued: "Patients prescribed anticoagulation medication should be given appropriate information on the risks and benefits of anticoagulants, in line with relevant clinical guidance and this should be clearly documented within the patient records. Relevant information about a patient’s death should (also) be effectively communicated to their family."
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