Decision Report 201304792

Summary

Mrs C complained about the care and treatment provided to her late father (Mr A) while he was in hospital. She was also unhappy with the board's response to her complaint.

During our investigation, we took independent medical advice from a geriatrician (a doctor specialising in medical care for the elderly). The advice we received was that, while several aspects of Mr A's care were good, and there was no evidence of major system failure or any actions that directly and adversely affected his physical health, in other areas his care fell below the level that he could have reasonably expected to receive. This included a failure to act on the findings of an x-ray and to provide further follow-up and monitoring, as well as a lack of communication with Mr A and his family while he was in hospital. We were concerned that these failings would have added to the distress that Mr A and his family were experiencing. We were, however, aware that the board had already taken action as a result of his case, in relation to improving communication with patients and their relatives, and were carrying out work around patient experience. The board had also apologised for the lack of communication and had carried out a debrief with staff. We were also concerned that there was a lack of communication with Mrs C while they were considering her complaint, and that the board had at first failed to fully respond to the issues she raised.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation;
• ensure that the findings of our investigation be included in consultant appraisals in relation to the specific incidents referred to in our report;
• apologise for the failings identified in the handling of the complaint; and
• ensure that complaint responses adequately and fully address the issues raised in a complaint.