Decision Report 201203646

Summary

Mr C complained about the quality of his care after he had a kidney removed. He said that he was not provided with adequate pain relief, his call buzzer was not working during his stay so he could not call for assistance, and he was inappropriately discharged, despite displaying symptoms of an infection. Mr C was readmitted with a wound infection six days after being discharged. He also complained that there was a delay in transferring him to an appropriate specialist unit and that he received poor care, resulting in an infected vein. Mr C did not believe that the board had taken adequate steps to prevent these problems happening again.

After taking independent advice from two of our medical advisers - on nursing care and the clinical decisions made - we found that the board had failed to provide adequate pain relief during Mr C's first admission to hospital and that the standard of care of intravenous cannulas (needles used to give drugs and fluids to a patient) was unreasonable. We also upheld his complaint that the buzzer was not repaired during his stay. We found, however, that although with hindsight he most likely had an infection when discharged, the actions of staff at the time were in line with acceptable clinical practice, that his second admission was handled appropriately and that the delay in his transfer was beyond the board's control.

Recommendations

We recommended that the board:

• apologise in writing for their failures; and
• carry out a serious critical incident review into the failure to provide adequate pain relief.