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Case ref:201708607
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Date:October 2018
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Body:Highland NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) at Belford Hospital. Mr A was admitted to hospital on a number of occasions over a short period of time for breathlessness and chest pain. Ms C complained about the clinical care and nursing treatment provided to Mr A, the board's communication with Mrs B about her husband's deterioration, and the post-mortem care (care after death) provided to Mr A.
We took independent advice from a consultant physician and from a nursing adviser. We found that there were a number of failings with regards to the clinical treatment provided to Mr A, and we upheld this aspect of the complaint. However, we found that the nursing care had been reasonable and so we did not uphold this part of the complaint.
Regarding communication, we found that there was a failure to discuss Mr A's deterioration with Mrs B in a timely manner, and so we upheld this part of the complaint.
We found that the post-mortem care provided to Mr A was reasonable, and we did not uphold this aspect of the complaint. However, we found that the board had not addressed Ms C's concerns around post-mortem care in their original complaint repsonse. We, therefore, made a recommendation regarding this.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mrs B for the failure to provide Mr A with reasonable clinical treatment, and for the failure to communicate reasonably with her about Mr A's deterioration. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future:
- Patient care should be in line with the Scottish Intercollegiate Guidelines Network guideline 139: Care of the Deteriorating Patient, and Healthcare Improvement Scotland guidance on Structured Response to the Deteriorating Patient.
In relation to complaints handling, we recommended:
- All issues raised in complaints letters should be addressed.