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Decision Report 201301889

  • Case ref:
    201301889
  • Date:
    May 2014
  • Body:
    Highland NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the care and treatment provided to his mother (Mrs A) when she was admitted to Cowal Community Hospital on two occasions. Mrs A had a history of persistent and worsening diarrhoea and was diagnosed with clostridium difficile (a type of bacterial infection that can affect the digestive system). She was discharged two weeks later and returned home. However, she was readmitted to the hospital after testing positive for clostridium difficile again.

Mr C complained about a number of aspects of Mrs A's care. We found that much of the treatment provided to Mrs A had been of a reasonable standard. She was able to make her own decisions and was entitled to ask to go home in her nightclothes when she was discharged and to ask staff to wait for her own clean clothes before changing her. We also found that the board's communication with Mrs A and her family had been reasonable and that the correspondence issued to her GP was in line with the required standard. Mrs A's nutritional care was also reasonable and the board had taken action in response to concerns Mr C had raised about her dietary needs and about clostridium difficile.

That said, we did identify some failings in relation to the care and treatment provided to Mrs A. We considered that the hospital should have carried out an assessment to ensure that she could get into her house safely when she was discharged. However, we noted that the board had apologised for this and had taken reasonable steps to try to prevent similar problems recurring. They had also been unable to provide evidence that transfer documentation was sent to another hospital when Mrs A was transferred there. In view of these specific failings, on balance, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

  • issue a reminder to the staff involved in Mrs A's care that discharge documentation should be completed, filed and stored.

Updated: March 13, 2018