STAFF should have been aware of a woman’s serious heart condition before she was discharged from the Borders General Hospital.

But, despite being diagnosed with pulmonary emboli at another hospital just days earlier, the patient was sent home – only to be re-admitted two days later suffering from breathlessness.

Now the result of a probe into how the diagnosis was missed – and what lessons can be learned – has been published by the Scottish Public Services Ombudsman (SPSO) following a complaint from the woman’s daughter.

Among a raft of recommendations, the watchdog says NHS Borders should “apologise for the standard of care and treatment provided”.

The report describes how the woman – referred to as Mrs A – was taken to the emergency department of the BGH after collapsing at home.

As she already had a pacemaker fitted and experienced a number of issues with her heart while at the BGH, she was transferred to another hospital in a different NHS board area for specialist investigations.

Tests revealed no abnormalities in her pacemaker, but her scheduled return to the BGH was prevented by an outbreak there of the norovirus winter vomiting bug.

“The second hospital carried out further tests and Mrs A was diagnosed with pulmonary emboli [blockages in the blood vessels from the heart to the lungs usually caused by blood clots],” states the report.

She was prescribed with the blood thinning agent warfarin and transferred back to the BGH a few days later.

“The medical transfer documentation did not include information about the new diagnosis and treatment, although the nursing transfer document specifically identified them. When Mrs A was readmitted to the BGH, staff only considered the medical transfer documents and missed the pulmonary emboli diagnosis.” Despite her daughter (Mrs C) expressing concerns about her mother’s ability to cope at home, she was deemed medically fit to do so and was discharged two days later. “Mrs A became increasingly breathless, however, and was readmitted two days later when the pulmonary emboli diagnosis was picked up and treated.” The report reveals that after Mrs C complained about the care her mother had received, the health board apologised for the “errors in communication” between the two hospitals. She was also advised that steps would be taken to ensure the issue was followed up with the other hospital and that doctors at the BGH would now check both medical and nursing transfer documents when admitting patients.

Mrs C then took the matter to the SPSO which sought advice from one of its medical advisers, a consultant physician.

“After taking independent advice, we upheld Mrs C’s complaint,” states the watchdog. “The adviser considered that the failure to identify Mrs A’s diagnosis from the nursing transfer document was unreasonable and that insufficient effort was made to assess her before she was discharged. We were also critical that there appeared to have been a delay in the board carrying out the actions advised in its response to Mrs C’s complaint.

“We recommend that the board should apologise for the standard of care and treatment provided to Mrs A during the period relating to the complaint; take steps to ensure actions agreed following a complaint investigation are followed up promptly; consider taking the views of family members into account and determine whether there are lessons that can be learned; and make medical staff involved in Mrs A’s care aware of concerns regarding the decision to discharge, including the lack of documentation, to ensure a similar situation does not occur in future.” Evelyn Rodger, Director of Nursing and Midwifery and Interim Director of Acute Services, said: “NHS Borders has accepted the recommendation in the SPSO report and have written and apologised to the patient for any distress caused by these events and that we were unable to resolve their concerns and queries through our local complaints procedure.

“We have assured the Ombudsman’s office that we fully recognise, and regret, the aspects of the patient’s treatment and complaint handling which did not meet expected standards and will take what has been learned from this experience to improve our service in the future.”