Decision Report 201601896

Summary

Mrs C complained about the care and treatment she received at the Queen Elizabeth University Hospital. She had been admitted to the hospital for routine bladder surgery, but due to complications, she had to remain in hospital for four months. She complained that the board failed to ensure that her nutritional needs were appropriately met during her time in hospital. We took independent advice from a consultant urologist. Mrs C had been referred to a dietician after she had been in hospital for around a month and staff had then commenced feeding nutrition directly into her blood stream. However, we found that she should have been referred to a specialist dietician to address her nutritional needs earlier in her admission. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the catheter care management she received in hospital. Her catheter had fallen out and the procedure to put this back in was carried out by a junior doctor. However, the catheter went into her bowel. Mrs C said that, as a result of this, she had to have an ileostomy (where the small bowel is diverted through an opening in the stomach abdomen). We found that this problem could not have been foreseen and that it could not be concluded that this would not have happened if a more senior doctor had carried out the procedure. The follow-up care Mrs C subsequently received had also been appropriate. We found that the actions of staff in relation to this matter had been reasonable and we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing to Mrs C for not referring her to a specialist dietician earlier. The apology should comply with SPSO guidelines on making an apology.

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

• Patients who will have a prolonged recovery time due to post-operative complications, particularly when it impacts their bowel and their nutritional requirements, should be assessed by a specialist dietician at the appropriate time.

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.