• Case ref:
    201502380
  • Date:
    May 2016
  • Body:
    Borders NHS Board
  • Sector(s):
    Health
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Upheld, recommendations

Summary

Mrs C complained that her late mother (Mrs A) did not receive appropriate care after she was admitted to Borders General Hospital. She also complained that the family were not informed in a timely manner when Mrs A's condition significantly deteriorated. In responding to the complaint, the board said that Mrs A's care was provided in a timely manner. However, they accepted and apologised that there was a failure by staff in informing the family about Mrs A's worsening condition when this was known.

We took independent advice from a consultant geriatrician. We identified evidence of poor record-keeping and that there was undue delay in identifying that Mrs A was significantly unwell. There was a delay of six hours in nursing staff checking Mrs A's blood pressure, which was contrary to national guidance. We also considered that blood tests could have been carried out sooner and that there was several hours' delay in staff taking the abnormal blood results into account after they were reported.

We noted there was a four-hour delay in the family being informed that Mrs A's condition had significantly worsened. Whilst the board apologised and had advised that they were taking action to address the matter, we asked for further evidence to demonstrate how this will prevent a similar delay occurring. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

  • apologise to Mrs C for not having identified Mrs A's deteriorating condition in a timely manner;
  • share the findings about record-keeping, blood testing, and blood pressure monitoring with the medical and nursing staff who were involved with Mrs A's care in the medical assessment unit;
  • conduct a review of care and treatment in the medical assessment unit to ensure timely care is provided to those patients at risk of rapid deterioration; and
  • provide more detailed information on the pilot they carried out in relation to improving communication and on whether this has been implemented throughout the hospital.