Decision Report 201302971

Summary

Mrs C raised a number of concerns about the care and treatment that her late mother (Mrs A) received at the Victoria Hospital during two separate admissions. Mrs A was taken to hospital with symptoms suggestive of a stroke. Tests showed that she had a lung tumour, and a biopsy (tissue sample) was taken several days later. She was discharged, but was readmitted four days later having suffered a major stroke. Mrs A died three months later.

We took independent advice on this case from our nursing adviser and one of our medical advisers, who is a GP. The GP adviser identified that a number of aspects of Mrs A's medical care fell below a reasonable standard. At the time of the first admission, more consideration could have been given to the stroke diagnosis and treatment, and there was an unreasonable delay in the lung biopsy being processed although we took the view that the board had since taken reasonable steps to address this. In respect of the second admission, the GP adviser said there was a lack of communication between specialist stroke staff and the family. We also found that, although Mrs A's medication was managed well on a daily basis, there was a need for more strategic consideration of this. There was delay in providing medication to address Mrs A's high calcium levels and her low mood. In addition, medication for nausea was stopped, and there was no reason for this given in the medical records. Our GP adviser was also critical that there were a number of undated entries in relation to blood results.

We noted that the board had acknowledged Mrs C's concerns that Mrs A's dignity was compromised and that on one occasion she was not properly clothed, and our nursing adviser was satisfied with the measures the board took to address this. In relation to the management of incontinence, pain levels, involvement from speech and language therapy and dieticians, along with Mrs A's care planning and rehabilitation work, there was evidence in the medical records to support that the overall nursing care was of an acceptable standard.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• review the comments of our GP adviser on this complaint and reflect on the decision-making processes used by GPs individually and collectively in assessing Mrs A, and provide us with evidence of this reflection having taken place and its outcome.