Scottish Public Services Ombudsman

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  • Report number:
    201102756
  • Date:
    September 2012
  • Body:
    Forth Valley NHS Board
  • Sector(s):
    Health
  • Keywords:
    Care of the elderly; clinical treatment; nursing care; record-keeping; policy/administration 19 September 2012 201102756

Overview
The complainant, Mr C, raised a number of concerns about the care and treatment given to his father (Mr A) during the final days of his life.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) nursing staff at Bannockburn Hospital (Hospital 1) failed to recognise that Mr A's condition was such that he required appropriate medical assistance (not upheld);
  • (b) two out-of-hours doctors who separately attended Mr A assessed and treated him inappropriately. In particular, they failed to recognise his poor condition and arrange for a transfer to Stirling Royal Infirmary (upheld);
  • (c) the decision making, care and communication of nursing staff in relation to the provision of palliative care for Mr A was inappropriate (upheld);
  • (d) nursing staff inappropriately refused to provide even the most basic of medical records to a medically qualified relative, despite him having Mr C's consent as next of kin with welfare power of attorney (not upheld);
  • (e) a staff nurse refused to allow a medically qualified relative to speak to Mr A's on call consultant and the on call consultant failed to recognise the importance of having this conversation (not upheld);
  • (f) an inappropriate care and treatment plan was agreed between the staff nurse and the on call consultant pending the arrival of an out-of-hours doctor (not upheld);
  • (g) during his stay in Hospital 1, Mr A's consultant failed to make himself available to meet with Mr C, who was next of kin with welfare power of attorney. This was despite Mr C's best efforts (not upheld); and
  • (h) during Mr A's stay in Hospital 1 there was an unacceptable level of care with regard to his possessions, which resulted in the unacceptable loss of his spectacles for some weeks and his hearing aid which was never recovered (not upheld).

 

Redress and recommendations
The Ombudsman recommends that Forth Valley NHS Board:

  • (i) complete a critical incident review regarding this situation, if they have not done so already;
  • (ii) consider the practicality of having routine discussions regarding care escalation for patients admitted to Hospital 1 and other similar units;
  • (iii) consider the means by which it can be ensured that severe illness is promptly recognised in such units, by use of a Scottish Early Warning Score or similar scoring system;
  • (iv) consider a strategy for determining the appropriate limits of care as soon as a patient in Hospital 1 or similar unit becomes acutely unwell and where there has been no anticipatory care discussion;
  • (v) emphasise to staff in Hospital 1 the importance of keeping full and proper records, including notes of conversations and telephone conversations; and
  • (vi) remind Hospital 1 staff of the Do Not Attempt Cardiopulmonary Resuscitation Policy and provide evidence that they have done so.

 

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201102756 as a PDF (146.54 KB)

Updated: May 20, 2013