Decision Report 201810404

Summary

Mr C complained about the care and treatment provided to him by the hospital when he had been admitted for a biopsy (a tissue sample taken for testing) and insertion of chest drain (a flexible plastic tube is inserted through the chest wall and into the affected area to drain it of fluid). He complained that pain relief had been inappropriate and caused urinary blockage; that there had been a failure to make a referral to his local hospital for urinary issues; and that his relatives had been informed there was a crash in his blood pressure, but that this was then denied.

We took independent advice from a surgeon. We found that the referral to Mr C's local urinary team was made appropriately and there was no evidence that Mr C had a blood pressure crash. However, we found that there were failures in Mr C's care and treatment in relation to the management of his pain; his pain was not assessed regularly and in line with the pain assessment chart, and the pain relief that was given was not adequate for Mr C's needs and was not in line with the British National Formulary on prescribing. We also found that management and monitoring of Mr C's urinary output and retention was unreasonable. We therefore upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failures in relation to the management of his pain, and management and monitoring of his urinary output and urinary retention. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .

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

• Medication given for pain relief should be adequate for the patient's needs and in line with the British National Formulary on prescribing.
• Pain levels should be assessed in line with the general pain assessment chart.
• Urinary output should be monitored closely after surgery and staff should be alert to the possibility of urinary retention.

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.