The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her husband (Mr C) by Forth Valley NHS Board (the Board) at Stirling Royal Infirmary (the Hospital) from 3 April 2006 until his death on 27 July 2006. Mrs C also raised concerns about the way in which the Board handled her complaint.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Consultant's actions denied Mr C the opportunity to make informed choices about treatment and end of life care and the Board failed to follow the Liverpool Care Pathway (upheld);
- (b) the Board failed to acknowledge the failings of the Consultant or to make changes or improvements to address the failings (upheld); (c) there was an unnecessary and lengthy delay in the Board's handling of the complaint (upheld);
- (d) the notes taken at a meeting with the Board's representatives did not fully and accurately detail the depth of Mrs C's concerns and the outcome she wished to achieve (upheld); and
- (e) Mrs C's request for a meeting with the Consultant was refused unreasonably (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake an external peer review in the Hospital, to include: the procedures relating to the management of biopsies, including communicating biopsy results; the current strategy for the policy of Living and Dying Well, with particular reference to the implementation of the Liverpool Care Pathway and the role of consultants; the education and training of staff, particularly consultants, relating to end of life care;
- (ii) ensure that the failings identified in this report are raised with the Consultant during his next appraisal, to ensure lessons have been learned from this case;
- (iii) provide evidence about how feedback from complaints is used as part of the consultant appraisal process;
- (iv) review their procedures to ensure they investigate complaints fully, in accordance with the NHS Complaints Procedure, with particular reference to timescales; and
- (v) apologise to Mrs C for the failures identified in this report.
The Board have accepted the recommendations and will act on them accordingly.