Decision Report 201302862

Summary

Mr C complained about the medical and nursing care and treatment he received in Raigmore, Broadford and Ross Memorial hospitals between June and December 2012. Mr C had a complex medical history and began to experience chronic back pain at the end of June 2012. This proved to be a lumbar disc infection and he was treated conservatively. Mr C complained about various aspects of his care and treatment during his various admissions to the hospitals including the frequency and standard of consultant review, treatment decisions, diagnosis, pain management, communication and the decisions to discharge him home or to other hospitals.

We took independent advice from a nursing adviser and two medical advisers, one in emergency medicine and the other in orthopaedics (conditions involving the musculoskeletal system). We found that the standard of medical care and treatment provided by Raigmore Hospital was reasonable and that the nursing treatment was also reasonable with the exception of the use of a commode for showering purposes. We made a recommendation to address this.

We also found that the standard of medical and nursing care and treatment provided by Broadford Hospital was reasonable. However, in relation to the standard of medical care and treatment at Ross Memorial Hospital, while we found no failings in relation to nursing care, we found that there was a missed opportunity to potentially manage Mr C's pain more effectively and that a planned discharge home was unreasonable. We made a number of recommendations to address these failings.

Recommendations

We recommended that the board:

• bring the shortcoming in nursing care to the attention of relevant staff;
• bring the failings to the attention of relevant staff;
• clarify referral procedures to the chronic pain team and ensure staff are aware of the procedure; and
• apologise for the failures we identified.