The Scottish Public Services Ombudsman said the patient – identified only as Mrs A – had been “wrongly administered” the drug Amoxicillin, a penicillin-based antibiotic, when she was known to be allergic to penicillin.
While her death was not due to this, ombudsman Jim Martin said there had been “unreasonable delay” in assessing and treating her condition as it worsened.
He stated: “It will be very distressing for Mrs A’s family to learn that the failings identified may have altered the outcome for Mrs A.”
His report said there had been “serious failings in care” and recommended NHS Lanarkshire apologise to the patient’s family.
The woman, who suffered from asthma, ischaemic heart disease and lung condition chronic obstructive pulmonary disease (COPD), was admitted to Monklands Hospital in Airdrie early in the morning of 26 December, 2014. She died in the hospital just over a week later on January 2, 2015.
Her husband, identified as Mr C, told ambulance staff who took her to hospital and medics working in the emergency department that she was allergic to penicillin, saying that on two previous occasions the drug had caused her to go into anaphylactic shock.
When the woman’s daughter, herself a nurse, visited the hospital on the evening of 26 December, she saw in medical records her mother had been given Amoxicillin.
The staff nurse who gave her the drug said she was “unsure” if Mrs A was wearing a red wristband, which would have identified her as suffering from allergies, at the time.
The ombudsman’s report said while there was “human error”, the failure by staff to follow drug administration policies “was a serious incident and represented serious failings in care”.
Mr Martin said: “In this case, we have decided to issue a public report on Mr C’s complaint because the failings I found led to a significant personal injustice to Mr C and his family, and because we considered the board’s own investigation had not fully acknowledged the seriousness of what happened in Mrs A’s case.”
The Ombudsman also highlighted a “failure by both nursing and medical staff to take appropriate action after Mrs A was wrongly administered Amoxicillin”.
Irene Barkby, director of nursing at NHS Lanarkshire, acknowledged that Mrs A’s care fell “below the standards”.