Decision Report 201811027

Summary

C complained about the care provided by the board during their admission to Woodend Hospital. C said that the board unreasonably administered an overdose of an opioid drug. We took independent advice from an appropriately qualified adviser. We found that the board failed to follow local protocol and unreasonably administered an opioid drug to C. We upheld this part of C's complaint.

C also complained that the board failed to reasonably monitor them after they underwent an operation. C was being monitored using National Early Warning Score (NEWS). NEWS is a guide used by medical services to quickly determine the degree of illness of a patient. We found that when C triggered a NEWS score of one, they should have been observed every four hours, however C was next observed 11 hours later. This was unreasonable and we upheld this part of C's complaint.

C complained that their spouse (B) was unreasonably communicated with after their condition deteriorated. We found that while it was identified in the morning of that day that B should have been contacted, B was not made aware of C's condition until they entered the ward almost eight hours later. This was unreasonable and we upheld this part of C's complaint.

The board said that they had already taken action in response to these failings. We asked them to provide evidence of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to communicate with them in a timely manner.
• Apologise to C for the failings as identified by the board and from our investigation. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.