Decision report 201101281

Summary

Mrs C told us that her late mother (Mrs A) was admitted to hospital for oesophageal (gullet) enlargement to help reduce a thin membrane that had formed in her gullet. This was to be a day procedure. However, following the procedure, Mrs A suffered complications and remained in the hospital where further surgery took place. Her condition worsened and she was transferred to another hospital in the board's area where she died. Mrs C and her family complained to the board that Mrs A received inadequate care and treatment, communication and nursing care while a patient in the hospital. Mrs C said that there was a failure to take Mrs A's visual impairment into account, and was dissatisfied with the response she received to her complaint.

Two of our medical advisers reviewed Mrs C's complaint and Mrs A's medical records. After carefully considering their advice, we found that there was no evidence that Mrs A had not received appropriate care and treatment from the hospital and from nursing staff. We also found that, overall, the communication with Mrs C, Mrs A and her family was acceptable. We did not uphold any aspects of these complaints.

However, one of our advisers, a nursing adviser, was critical of the lack of documented information and care planning about Mrs A's visual impairment. We considered that the board failed to take Mrs A's visual impairment into account and upheld this complaint.

Recommendations

We recommended that the Board:

• ensure that, where a patient is visually impaired, this is recorded and taken into account of in their nursing assessment and care plan; and
• advise us of the outcome of any discussions with the Royal National Institute of Blind People concerning measures to improve the future care of patients with visual impairment.