Patient transferred to maternity ward against NHS policy amid 'extreme pressure'

A patient was transferred to a maternity ward against NHS policy amid “extreme pressure” at a hospital.

The Scottish Public Services Ombudsman (SPSO) received a complaint from the patient’s child after they died.

They were receiving treatment in hospital for a chest infection and pleural effusion, which is a build-up of fluid in the chest.

During a visit, the patient’s child was told that the bed was needed for a more acute patient, and that their parent would be moved to a maternity ward as a boarder.

The patient’s child complained that they were worried this would negatively impact their parent’s care and wellbeing, and that the family had felt pressured to accept the move.

NHS Greater Glasgow and Clyde said the patient had been identified as suitable for boarding, something that may be necessary when there is extreme pressure on capacity, and that their care had not been affected by the move.

In investigating, the SPSO took independent advice from a consultant specialising in acute medicine.

It was found that the patient was “not considered suitable” for boarding under the health board’s own policies.

There had been a “failure to conduct and record” a proper risk assessment before the move, and a failure to record the deviation from policy.

The ombudsman found evidence that the move caused the patient distress, leading to a “deterioration in their behaviour and acceptance of treatment.”

As part of its recommendations, the watchdog asked the health board to apologise to the patient’s child.

It also advised that “appropriate clinical considerations and a formal risk assessment” should be made when deciding to board a patient.

Morag Gardner, NHS Greater Glasgow and Clyde’s deputy nurse director for Acute Services, said: “We would like to reiterate our apology to the family of this patient, and we send our deepest sympathies for their loss.

“While we cannot comment on individual cases due to patient confidentiality, we know that some aspects of this patient’s care in late 2022 and early 2023 did not meet the standards expected, and we are sorry for that.

“We have fully considered the report and accept the recommendations that have been made.

“We are working with our teams to ensure learning is taken forward and that the recommendations are met in full.”