Decision Report 201301136

Summary

Mrs C complained that communication from staff and the care provided to her husband (Mr C) in Caithness General Hospital were inadequate. Mr C had been taken to A&E after collapsing, and although Mrs C thought he had symptoms of a stroke, he was discharged. The board said that this was because Mr C did not want to stay in hospital overnight. He suffered a significant stroke shortly afterwards. Mrs C also complained about the nursing care after her husband was admitted to hospital, saying that when visiting him the next day she found him in a side room, lying on a mattress on the floor. She was distressed that Mr C's dignity was compromised, as he was not wearing pyjama bottoms.

After taking independent advice from one of our medical advisers and our nursing adviser, we upheld all Mrs C's complaints. We found that the junior doctor and the consultant physician involved did not give enough consideration to Mr C's diagnosis, particularly to the likelihood that he had suffered a minor stroke. Had they done so, it might have led them to have assessed the risk of this happening again and provided treatment if appropriate. However, our medical adviser pointed out that the outcome for Mr C might not have been different even had he been admitted to hospital at the start.

Although both the nursing staff and the doctors had indicated in the clinical records that Mr C did not want to stay overnight, there was no clear written information to show that they had recommended that he should be admitted before having an urgent scan in the morning. As the doctors had not indicated what they thought was wrong with Mr C, he would not have been aware of any potential risks in being discharged. We considered that the communication with Mr and Mrs C fell below a reasonable standard. We also found that the nursing staff should have told Mrs C before she visited that they were nursing Mr C on a mattress on the floor, to reduce the likelihood of him falling out of bed. The board had acknowledged that his care in terms of his dignity was unreasonable and had taken steps to address this with relevant nursing staff.

Recommendations

We recommended that the Board:

• draw to the attention of the junior doctor and the consultant physician our findings in relation to the lack of consideration given to Mr C's initial diagnosis;
• draw to the attention of the junior doctor and the consultant physician the importance of ensuring that communication about likely diagnosis is clearly explained to patients and their families where appropriate; and
• apologise to Mr and Mrs C for the failings we identified in Mr C's care.