Overview
The complainant, Ms C, raised a number of concerns about the care and treatment that her uncle, Mr A, received in Vale of Leven Hospital (Hospital 1), between his admission on 23 January 2006 and his transfer to Gartnaval General Hospital (Hospital 2) on 8 February 2006. Sadly, Mr A died on 8 March 2006.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Mr A was given inconsistent advice (no finding);
- (b) Mr A's pain was not managed effectively between 28 January and 8February 2006 (upheld);
- (c) Mr A's pressure sore could have been avoided (upheld);
- (d) Mr A should have been referred to the vascular surgeons more quickly (upheld);
- (e) Mr A's room was not clean and this contributed to his illness (not upheld); and
- (f) Mr A was inappropriately referred to as a problem patient (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) remind staff of the need to ensure they respond in full to formal complaints;
- (ii) ensure that the clinical team responsible for Mr A's care in Hospital 1:
- (a) review this report; consider what lessons can be learned from Mr A's experience and review how pain is managed effectively;
- (b) are aware of the need for accurate records to be kept; and
- (c) utilise best practice statements on Pressure Ulcer Prevention and the Treatment and Management of Pressure Ulcers issued by NHS Quality Improvement Scotland (March 2005 and November 2005);
- (iii) audit the use of MRSA screening on Ward 14 and report back to her proof of review and change in practice;
- (iv) ensure that the clinical team consider the lessons to be learned as a result of the failings identified in this report and report back to her changes in practice put in place as a result; and
- (v) apologise to Ms C fully and formally for the failings identified in this report;
The Board have accepted the recommendations and will act on them accordingly.