Decision Report 201406914

Summary

Mrs C, who is an advocacy worker, complained to us on behalf of her client (Mrs B) whose mother (Mrs A) had been a patient at Dr Gray's Hospital after being admitted with symptoms of abdominal pain, nausea, vomiting and with an infection. While in the hospital, Mrs B had concerns about her mother's clinical treatment and nursing care. These included a delay in diagnosing that Mrs A had fluid on her lungs and that the staff did not listen to the family's reported concerns about possible fluid build-up; that they did not provide Mrs A with assistance to mobilise; and that staff failed to communicate with them regarding Mrs A's condition and test results. Mrs B was also concerned that the board's formal response did not address all her concerns.

We took independent advice from a clinical adviser and a nursing adviser. We found that although the day-to-day clinical treatment which was provided was reasonable, there was a slow pace to the investigations and there was a clear lack of clinical direction. It was accepted that there were numerous medical specialties involved and that there was some uncertainty regarding a definitive diagnosis. However, there was a lack of any thoughtful or dynamic approach to Mrs A's care. We also found that the nursing care was appropriate but there were failings in communication by both nursing and clinical staff. We also found evidence of poor complaints handling as the board had not addressed all of Mrs C's concerns which were set out in the initial complaint letter to them. They had only generally referred to the communication issues and failed to address any of the concerns regarding the nursing care.

Recommendations

We recommended that the board:

• apologise to Mrs A for the way her clinical treatment was managed and for the subsequent delays to her treatment;
• share our findings with senior clinicians who were responsible for Mrs A's treatment in order that they can reflect on their actions;
• apologise to Mrs A for the failings in communication which we identified;
• share our findings with nursing and clinical staff in order that they can reflect on their actions;
• apologise to Mrs B for the inadequate response to her formal complaint; and
• remind all staff who are responsible for investigating complaints to ensure that all concerns are addressed in the final response.