Decision Report 201507956

Summary

Ms C complained about the care and treatment of her brother (Mr A). Mr A was diagnosed with liver disease and admitted to the acute medical unit at Ninewells Hospital a few weeks later. During the admission, he was also given medication for alcohol withdrawal. Mr A was diagnosed with acute kidney injury and treated with dialysis (a form of treatment that replicates many of the kidney's functions). Mr A's condition worsened suddenly, and he was transferred to intensive care, where he died.

Ms C raised a number of concerns, including that Mr A was missed during the doctor's ward round the morning after his admission and that he was not referred to kidney specialists sooner. Ms C felt the hospital was under-staffed over the weekend, and she felt this meant that Mr A's condition was not taken seriously until it was too late. Ms C was also concerned that Mr A was given varying doses of medication, instead of commencing with a high dose which is slowly reduced.

The board conducted an adverse event review of Mr A's admission. They acknowledged some failings, including that Mr A was missed on the ward round, that some of the nursing documentation was not fully completed, and that the family should have been told sooner how serious Mr A's condition was. The board apologised to Mr A's family, discussed the learning from the complaint with staff and agreed a new process for ward rounds to ensure that patients who are being moved are not missed. The board also met with Ms C to discuss the complaint, but Ms C found the meeting unhelpful and brought her complaint to us.

After taking independent medical and nursing advice, we upheld Ms C's complaints about medical care and communication.

While we found there were some omissions in nursing documentation, we found that the overall standard of nursing was reasonable. We found the administration of the medication was appropriate, as this was given as needed, using a scoring system to assess Mr A's symptoms. While we noted that Ms C disagreed with many points of the board's response to her complaint, we did not find failings in their complaints handling. However, we made some suggestions regarding how the board could improve their complaints handling practice by inviting people who request a meeting to confirm the issues they want addressed in advance of the meeting.

Recommendations

We recommended that the board:

• demonstrate to us what steps they have taken to reassure themselves that the new system for ensuring consultant reviews of incoming patients on the acute medical unit is effective.