THE SCOTTISH Public Services Ombudsman (SPSO) has told NHS Shetland to apologise over how it handled a review into a patient being given inappropriate advice.
A woman, known as Mrs C, had complained that midwives at Gilbert Bain Hospital failed to recognise that she had hypnotraemia, or low blood sodium levels.
She was told to drink more fluids, but that made her condition worse.
A midwife advisor for the SPSO ruled that the midwives carried out “appropriate observations and tests” in light of her symptoms. The SPSO did not uphold her complaint in that respect.
But the SPSO noted that after NHS Shetland undertook a review of the situation, there was a delay in sharing the action plan with the patient.
It ordered NHS Shetland to apologise to the patient for “failing to appropriately identify the learning from their case and share it with them at the time” – something that the health board said it has now done.
The ombudsman said reviews should be transparent and any learning should be shared with all those involved in the adverse event, including patients.
They also said that the health board should provide a reasonable standard of care to patients with hyponatraemia, whatever the underlying cause, with adequate staff training in place to support this.
A spokeswoman for NHS Shetland said: “We acknowledge the findings and recommendations made by the Scottish Public Services Ombudsman and appreciate the opportunity to learn from this review.
“We welcome the fact that the SPSO found the actions taken by the midwives were reasonable in the circumstances.
“We can confirm we have progressed all the actions identified by the SPSO, including apologising to the family in relation to the experience that they had.”
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