Decision Report 201404703

Summary

Mrs C complained on behalf of her husband (Mr C) about his care and treatment in Monklands Hospital. In particular, she believed that an x-ray taken immediately before his admission showed sufficient evidence of respiratory problems that he should not have been allowed home, only to be admitted the next day as an emergency. She further complained that, once in hospital, Mr C should have been kept in either intensive care or in a high-dependency unit, and not moved between wards as he was. Mrs C also said that insufficient care was taken to prevent him falling, and that a nil-by-mouth (NBM) instruction was ignored.

We took independent clinical advice from two advisers, a consultant respiratory and general physician and a nursing adviser. We found that Mr C had been discharged after his x-ray without the results being seen or taken into account, and without him being given appropriate treatment. In light of this, this part of his complaint was upheld. Similarly, we found that staff did not adhere to an NBM instruction and this complaint was also upheld. However, after he was admitted to hospital, all ward transfers were made with Mr C's medical condition in mind and were all appropriate. The evidence also showed that staff took all reasonable steps to prevent Mr C from acquiring pressure ulcers or from falling.

Recommendations

We recommended that the board:

• bring the comments of the consultant respiratory and general physician to the attention of the consultant neurologist concerned;
• make a formal apology for their communication failures;
• remind relevant staff (nurses and doctors) of the necessity of good, clear communication;
• apologise to Mr and Mrs C for their failure to follow Mr C's NBM instruction; and
• emphasise to relevant staff the importance of following a NBM instruction.