Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    September 2014
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Not upheld, no recommendations


Miss C's mother (Mrs A) had been diagnosed with cancer, and admitted to Ayr Hospital. She was discharged, but was readmitted four days later with a chest infection. During Mrs A's admission, Miss C and her sister met with the palliative care nurse (a nurse specialising in care solely to prevent or relieve suffering) to discuss support for caring for Mrs A at home. They told the nurse and doctor that Mrs A wished to return home as soon as possible, and the nurse agreed to refer Mrs A to the hospice home care team.

The palliative care nurse was away from the hospital the next day, but intended to make the referral when she returned the day after. At that time, the nurse and the doctors expected that Mrs A would be in hospital until the next week for treatment for her chest infection. However, Mrs A discharged herself, against medical advice. The ward staff were not able to contact the palliative care nurse, but told Mrs A's GP that she had discharged herself, and arranged for district nurses to visit. Miss C called the hospice home care team for support, but was told that no referral had been made and that hospice support would, therefore, not be available until the following week. The hospice team then called the palliative care nurse, who immediately processed the referral. Mrs A died at home three days after discharging herself, before hospice support was put in place. Miss C then complained that the nurse had unreasonably delayed in referring Mrs A to the hospice home care team.

After taking independent advice on Miss C's complaint from one of our advisers, who is an experienced nurse, we did not uphold it. Our adviser said that, in the circumstances, it was not unreasonable for the nurse to wait a day before making the referral, as she had expected Mrs A to be in hospital until the following week. Our adviser also said that ward staff had taken reasonable steps to try to contact the palliative care nurse and to arrange some support for Mrs A by contacting her GP and district nursing.

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Updated: September 24, 2014