Decision Report 201404431

Summary

Mrs C complained about the poor communication by Victoria Hospital in relation to her father (Mr A), who had been receiving dialysis treatment (a form of treatment that replicates many of the kidney's functions). Following a discussion with Mr A's family, the medical team at the hospital decided to stop the treatment, but they did not tell Mr A's GP that they had done so. The GP didn't found out that Mr A required palliative care until a home visit three weeks later.

In response to Mrs C's complaint, the board said the consultant in charge was unable to locate the letter he dictated after meeting with the family. The board apologised for this and said that the consultant would try to ensure that in future information is passed on appropriately. Mrs C was dissatisfied with the response, as the board did not explain whether the letter was in fact dictated or typed, or whether the consultant had any recollection of signing it. Mrs C also considered that the board's response was not robust enough to prevent a reoccurrence of the situation, and she brought her complaint to us.

After taking independent medical advice, we upheld Mrs C's complaint. We found that the consultant had failed in his responsibility to inform the GP of Mr A's discharge (with the most likely explanation being that the letter was never dictated). We were also critical that the consultant did not give a clearer response to Mrs C's complaint, as this could have resolved it at an earlier stage. We noted that the board had already apologised to Mrs C and taken steps to improve their system for signing letters. As the failing in this case appeared to be caused by human error, rather than a system failure, we considered that asking the consultant to reflect on his practice was an appropriate and proportionate response.

Recommendations

We recommended that the board:

• bring the findings of our investigation to the attention of the relevant consultant, for reflection as part of his next annual appraisal.