Decision Report 201606636

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) on a number of occasions that he was admitted to Southern General University Hospital. Mr A suffered from a number of medical conditions, including heart failure, vascular disease, kidney impairment and epilepsy. Mrs C said that he was not treated holistically and she complained that her concerns about this were ignored. Mrs C said that this had severe consequences and that, when Mr A died, the family were totally unprepared and shocked as they had been given no indication of the seriousness of his condition. Mrs C also complained that Mr A had not been offered palliative care towards the end of his life.

The board accepted that communication with Mrs C and the family had been poor, but said that the nature of Mr A's condition meant that it could change very quickly. The board considered that Mr A had been treated and cared for reasonably.

We took independent advice from consultants in acute medicine and cardiology and from a senior nurse. We found that communication with the family was limited and that there was very poor documentation of what was said. We found that staff did not respond to the issues Mrs C and her family raised with them. We further found that there was no evidence to suggest that Mr A's seriously deteriorating condition was discussed with the family, and that opportunities to do so were lost. As a consequence, the family were unprepared for Mr A's death. Finally, we found that there were no discussions about palliative care. Had these taken place, there would have been an opportunity to establish what Mr A's wishes were and how to best manage his symptoms. We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for:
• failing to respond to her concerns
• failing to advise her and the family about Mr A's condition
• missing opportunities to start a discussion about palliative care
• The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Any concerns raised by a patient's family should be recorded appropriately in the notes.
• Where appropriate, families should be kept fully informed of a patient's medical condition and the options for treatment.
• Unless otherwise indicated, patients and their families should be given clear and honest information about the severity of illness and risk of death.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.