Decision Report 201901927

Summary

C was taken into Queen Elizabeth University Hospital for a kidney removal after the discovery of a cancerous cyst. A few days after the operation they were detained under the Mental Health Act and transferred to Stobhill Hospital. C believed they were not physically fit for discharge at that stage, and that there was insufficient evidence of risk to justify detaining them. In addition, they considered that their medication was mishandled throughout their time in both hospitals and that staff failed to treat them with respect and dignity. C is also blind and felt that the board had failed to reasonably take account of this in the way they interacted with and cared for them.

We took independent advice from a nephrologist (a doctor who specialises in kidney care and treating diseases of the kidney), a psychiatrist and a nurse. We found that C's care and treatment was generally reasonable, with the exception of the handover between the two hospitals, which was insufficient and led to problems with the dosage of C's medication. On this basis, we upheld C's complaint that the board failed to provide reasonable clinical treatment, but did not uphold their other complaints.

Recommendations

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

• Reasonable handover notes should be provided when patients are transferred between hospitals, to ensure continuity of care.

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.