Investigation Report 200602412

  • Report no:
  • Date:
    April 2009
  • Body:
    Forth Valley NHS Board
  • Sector:


The complainant, Mrs C, raised several concerns about the care and treatment provided to her mother (Mrs A) at Stirling Royal Infirmary, following her admission on 29 May 2006. Mrs A did not respond to treatment and the decision was taken to pursue palliative treatment only. Sadly, Mrs A died on 7 June 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

  • (a) it was proposed, inappropriately, to send Mrs A to a ward where her family could not be guaranteed to have access to her at all times (upheld);
  • (b) the bed managers initiated inappropriate conversation in Mrs A's room (upheld);
  • (c) when Mrs A moved from a High Dependency bed, intravenous medication was stopped and no adequate alternative medication was arranged (upheld);
  • (d) medical staff failed to review Mrs A's medication (upheld);
  • (e) the response to Mrs C's complaint was inadequate and did not address her concerns (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board (the Board):

  • (i) apologise to Mrs C for the shortcomings identified in this report and specifically for the actions of the bed managers;
  • (ii) review the operation of the Palliative Care Manual in relation to the bed management of terminally ill patients;
  • (iii) ensure that this incident is discussed at the bed managers' annual appraisals;
  • (iv) remind staff of the importance of documenting concerns raised by patients and their families in the patient's clinical records;
  • (v) review their pain management documentation and recording;
  • (vi) demonstrate how they will ensure that the two documents Living and Dying Well and Palliative and End of Life Care in Scotland can be implemented and that such change in practice can be reviewed by all hospital staff on a regular basis;
  • (vii) conduct an audit in prescription chart recording over a six month period;
  • (viii) ensure that night staff recognise when there is a need to contact on call staff to review medication for patients in pain; and
  • (ix) ensure that information is obtained from the staff involved to allow complaints to be investigated appropriately and all issues raised in complaints are addressed.

The Board have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018