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Decision Report 201507581

  • Case ref:
    201507581
  • Date:
    June 2016
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    policy / administration

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at Aberdeen Royal Infirmary. Mr C accepted an apology and explanations from the board for a number of his concerns, but Mr C was not satisfied with the board's response to his concern relating to his wife's DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) status. Mr C was not satisfied that the hospital staff in the gastroenterology department had followed the DNACPR policy and disputed the accuracy of a record which stated that a doctor had discussed the decision with him and his wife. We took independent advice from a consultant physician who was critical of the failure to complete a DNACPR form and the low level of detail in the medical notes surrounding the decision. We upheld this part of Mr C's complaint.

Mr C also complained that the board had taken a number of months to provide him with a written response to his complaint and had exceeded their target response time. Mr C was also concerned that the board had not sufficiently investigated his complaint and he was not satisfied with the response that the board had given him. We acknowledged that, in investigating Mr C's complaint, the board had met with him on two occasions and that this had contributed to the delay in providing a response. However, we remained critical about the individual delays that contributed to the time it took the board to respond, and found that the board had failed to keep Mr C updated on the progress of their investigation into his complaint. We also upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

  • apologise to Mr C for failing to adhere to the DNACPR policy;
  • provide evidence that staff in the gastroenterology department have been reminded of the importance of completing DNACPR forms where appropriate;
  • provide evidence of any audit or quality improvement work which has monitored the completion of DNACPR forms in the gastroenterology department since staff were reminded to complete the forms;
  • apologise for the failure to keep Mr C updated on the progress of their investigation into his complaint and failure to respond to his emails; and
  • advise staff responsible for investigating complaints to update complainants in line with 'Can I Help You?' guidance.

Updated: March 13, 2018