Overview
The complainant (Mrs C) raised a number of concerns about her husband (Mr C)'s care and treatment when he was admitted to the Emergency Department of Aberdeen Royal Infirmary on 19 November 2012.
She said that despite being assessed at 09:20 for transfer to the Acute Medical Assessment Unit he was not transferred there until 20:18. In the meantime, he had been lying on a trolley. Once transferred, Mrs C said that there was a delay in him seeing a doctor and that his condition continued to decline. Regrettably, Mr C died at noon the next day and Mrs C further complained about Mr C's appearance when she arrived in hospital after his death.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the care and treatment given to Mr C on his admission to hospital in November 2012 were unreasonable (upheld);
- (b) Grampian NHS Board (the Board) unreasonably asked Mrs C to sign Mr C's death certificate before she had been given a chance to see him (upheld); and
- (c) the Board unreasonably failed to properly lay out Mr C before Mrs C saw him (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- apologise to Mrs C for the fact that Mr C was not examined further by the medical team whilst he was still in the Emergency Department;
- provide a plan detailing the changes they have made to prevent such a recurrence (that is, missing target times and a failure to assess and treat in a timely manner);
- confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff;
- emphasise to all staff in the Emergency Department the importance of keeping accurate and timely clinical records;
- advise me of the steps they have taken to ensure that staff are aware of their responsibilities in similar circumstances and to be alert to the sensitivities of family members;
- take steps to ensure that this does not happen again and emphasise to all appropriate staff the necessity of preserving a patient's dignity in death; and
- be sensitive to the needs of close family members in such matters and advise appropriate staff accordingly.
The Board have accepted the recommendations and will act on them accordingly.