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Case ref:201402714
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Date:October 2015
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:admission / discharge / transfer procedures
Summary
Ms C, who is an advice worker, complained on behalf of Mrs A's family about the care and treatment provided to Mrs A by Southern General Hospital when her life-support machine was switched off. Mrs A was admitted to hospital after sustaining a severe injury at home, and put on a life-support machine. After being told by hospital staff that she could not survive, the family agreed to switch off the life-support machine. However, unexpectedly, Mrs A continued to live for a further 20 days. During this period, the family said there were communication failures; they did not know what was being done and what to expect in terms of care. They were also concerned that staff failed to provide appropriate care, particularly in relation to pain relief, fluids and nutrition. At the end of Mrs A's life, she was transferred to another hospital (Glasgow Royal Infirmary). The family said that her medical records were not transferred with her which meant that appropriate care could not be provided within a reasonable time at the second hospital. Finally, the family complained about the way the board had handled the complaint.
We took independent advice from one of our medical advisers. We found that the standard of care provided in relation to medication, nutrition and fluids was reasonable, and that sufficient information accompanied Mrs A when she was transferred to the second hospital. We were also satisfied that the evidence indicated that the family were kept fully informed of Mrs A's condition and prognosis. However, we found that the language the board used in their response to the complaint was inappropriate and insensitive, and that the response was overly technical and difficult for a layperson to understand.
Recommendations
We recommended that the board:
- take steps to ensure that Glasgow Royal Infirmary are complying with Records Management: NHS Code of Practice (Scotland);
- ensure that appropriate and sensitive language is used in complaint responses; and
- apologise for the failures this investigation identified.