South of Scotland

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late husband (Mr C) by Ayrshire and Arran NHS Board (the Board) between June 2011 and August 2011. Mr C, who was 80 years old, was admitted to Crosshouse Hospital (the Hospital) on three occasions during this period after breaking his hip. He had type 2 diabetes, hypertension, ischaemic heart disease and urinary incontinence and was on a number of medications before the series of admissions. He was finally discharged home on 8 August 2011, but died eight days later.

Specific complaints and conclusions

The complaints which have been investigated are that staff at the Hospital:

(a)  failed to appropriately assess Mr C’s complex medical conditions (upheld);

(b)  wrongly decided to withhold Mr C’s numerous types of medication and failed to keep his medication under review (upheld); and

(c)  failed to provide Mr C’s GP with sufficient and timely information about his condition on discharge from hospital (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  review their policies and procedures for patients with diabetes admitted to non-specialist wards to ensure that adequate systems in the management of their care are in place;

(ii)  issue a reminder to the relevant staff involved in MrC's care of the requirement to: keep clear, accurate and legible records; promptly provide or arrange suitable advice, investigations or treatment where necessary; consult colleagues where appropriate; and, refer a patient to another practitioner when this serves the patient’s needs;

(iii)  make the relevant staff involved in Mr C's care aware of our finding in relation to the failure to keep the decision to stop his medication under review;

(iv)  remind the relevant staff involved in Mr C's care that when an episode of care is completed, they should tell a patient’s GP about: changes to their medicines; the length of intended treatment; monitoring requirements; and any new allergies or adverse reactions identified; and

(v)  issue a written apology to Mrs C for the failings identified in this report.

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

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her husband (Mr C), who was admitted to Raigmore Hospital (the Hospital) on 4 January 2012 after suffering a seizure. She complains that during his stay, Mr C was not given appropriate care and treatment, nor was he properly assessed for rehabilitation prior to his discharge.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) staff at the Hospital failed to provide Mr C with appropriate care and treatment following admission on 4 January 2012 (upheld); and
• (b) staff at the Hospital failed to assess properly whether Mr C would benefit from rehabilitation on discharge from hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make a formal apology to Mr and Mrs C for their failures;
• (ii) ensure that the consultant physician (Doctor 2)'s next appraisal includes this case, together with reflection on the Adults with Incapacity legislation and the specific rights of patients with dementia;
• (iii) conduct an audit on Ward 6C, relating to compliance with Adults with Incapacity legislation for patients with dementia, and satisfy themselves that all staff are fully apprised of its implications;
• (iv) formally apologise to Mr and Mrs C for failing to assess Mr C properly prior to his discharge from hospital; and
• (v) (with Mrs C's agreement) assess Mr C thoroughly to establish whether he would benefit from further physiotherapy input and, if he would, the Board arrange this.

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

Overview
The complainant (Ms C) raised a number of concerns about the care and treatment her late daughter (Miss A) received at Raigmore Hospital (Hospital 1). Miss A was seen by an out-of-hours GP at Hospital 1 and thereafter returned 24 hours later where she was admitted as her condition had seriously deteriorated. The following day, Miss A was transferred to the Royal Hospital for Sick Children in Edinburgh (Hospital 2) and sadly died two days later.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the receptionist failed to obtain appropriate assistance when Miss A presented at Accident and Emergency with soiled clothing (upheld);
• (b) Miss A was inappropriately discharged by the out-of-hours GP on 5 March 2011 (not upheld); and
• (c) staff failed to adequately monitor or provide timely treatment to Miss A when she was admitted to Accident and Emergency on 6 March 2011 (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence to support that they have reviewed their gown supplies in Accident and Emergency and informed relevant staff of the procedure to follow when alternative clothing is required;
• (ii) remind the out-of-hours GP of the GMC's guidance in relation to record-keeping;
• (iii) draw to the attention of relevant staff the comments by Adviser 2 and Adviser 3 regarding documenting more detailed information on intubation in this case; and
• (iv) conduct a review of their Significant Event Analysis procedures to ensure that a detailed and robust investigation is carried out in all cases.