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Decision Report 201700480

  • Case ref:
    201700480
  • Date:
    December 2017
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained about a number of aspects of the care and treatment provided to her late mother (Mrs A) during two admissions to Queen Elizabeth University Hospital. Ms C complained that the standard of clinical care and treatment provided to her mother was not reasonable. Ms C also complained that the nursing care provided to Mrs A was not reasonable. Ms C's third concern was regarding the board's communication with Mrs A and the family during the admissions.

We took independent advice from a cardiologist and a nursing adviser. We found that the clinical care and treatment provided to Mrs A was reasonable. We found that the medications prescribed were appropriate and that Mrs A was reasonably reviewed. Whilst there was a failure to refer Mrs A to a heart failure nurse when she was discharged, we found that this was picked up at a later out-patient appointment and that an earlier follow up would not have impacted on Mrs A's treatment. We did not uphold this aspect of Ms C's complaint.

With regards to nursing care, we found that, whilst for the most part the nursing care was reasonable, the fluid balance charts were not always complete. We found this to be unreasonable and we upheld this aspect of Ms C's complaint.

Finally, based on the records available, we found that the board's communication with Mrs A and the family was reasonable. We did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C for failing to complete fluid balance charting.

What we said should change to put things right in future:

  • Nursing staff should complete all care rounding charts, including fluid balance charts, as required.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: March 13, 2018