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Case ref:201600986
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Date:November 2017
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:nurses / nursing care
Summary
Ms C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Ms C complained that the board had failed to provide a reasonable standard of nursing care to Mrs A's late husband (Mr A) when he was a patient at Inverclyde Royal Hospital. Ms C further complained that the board failed to provide Mr A's family with a definitive cause of death, and that their significant clinical incident investigation was not completed in a timely manner.
We took independent advice from a nursing adviser and a consultant physician. We found that there were failings in the nursing care provided to Mr A and we upheld this complaint. However, we considered that the board had appropriately identified and apologised for these failings, and had carried out a large number of improvement actions. We did not make any recommendations in relation to this aspect of Ms C's complaint.
We found that, whilst it was reasonable that clinicians were initially uncertain as to Mr A's cause of death, it was unreasonable that they disagreed about it in front of Mrs A and other family members at a meeting. Therefore, we upheld this complaint. We noted that the board had apologised for this matter, and we made a recommendation in relation to this aspect of the complaint.
Finally, we found that the board had unreasonably failed to complete their significant clinical incident investigation report in a timely manner, and we upheld this aspect of the complaint. However, we found that the board had taken appropriate action to address this failing and so we did not make any recommendations in this regard.
Recommendations
What we said should change to put things right in future:
- When appropriate, a preparatory meeting of the staff involved should be carried out prior to meeting with families about complaints, in order to allow meetings to go more smoothly and to avoid potential disagreements amongst staff in front of families.
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.