Health board says sorry after hastily discharging elderly woman who died

Shetland Health Board has apologised for the death of an elderly woman after an inquiry by the Scottish Public Services Ombudsman ruled that she was discharged from hospital too quickly.

Eileen Peterson died of pneumonia on 9th March 2005 – the same day she was discharged from hospital and taken back to the care home she had been staying in.

The 84-year old had initially been admitted to hospital after suffering from a number of falls and a suspected urinary tract infection.

However following an overnight stay she was discharged after a consultant physician ruled she would receive adequate care at Taing House.

Following her death her grieving son Michael Peterson complained to the ombudsman that she should have been kept in hospital for longer.

Now, following two-year investigation, ombudsman Jim Martin has largely upheld his complaint.

One adviser to the ombudsman said the patient had spent “an unsettled night” in hospital due to her levels of confusion, and there was no evidence of this resolving itself before she was discharged.

The inquiry also upheld the view in part that reasons for prescribing certain medications were unclear, and that staff failed adequately to assess and record treatment and care requirements.

The ombudsman further upheld the view that Mrs Peterson was given insufficient fluids during her stay in hospital. It found the recording of her fluid intake was poor, with only intravenous fluids being recorded on a fluid chart.

An advisor to the ombudsman said a lack of fluid intake was “a serious shortcoming in her care”.

The ombudsman recommended health board staff share his report with staff involved in Mrs Peterson’s care to allow them to reflect on the findings. Recommendations were also made to improve discharge planning.

The ombudsman also recommended that the board apologise to the patient’s family.

The findings of the investigation are at odds with those of a fatal accident inquiry in July 2006 into the circumstances of Mrs Peterson’s death.

Then, Sheriff Principal Sir Stephen Young QC ruled hospital and care staff could not be blamed for the patient’s death.

He even indicated the inquiry should never have been held in the first place, as Mrs Peterson had been “a frail old lady who was overwhelmed by a disease, namely pneumonia”.

In a written statement acting chief executive of NHS Shetland Dr Sarah Taylor said the board would consider the ombudsman’s report at its next meeting in September.

“The board has received the ombudsman’s report and has written a letter of apology to the complainant,” she said. “The board will consider the ombudsman’s report and the actions taken by the service in response to this case at its next meeting on 8th September.”

Mr Peterson refused to comment to The Shetland Times until he had studied the report in more detail.


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