Overview
The complainant Mr C was concerned about the care and treatment provided to his late wife (Mrs C). He said that a delay in the initial diagnosis of her cancer meant she had to attend the hospital daily for injections for suspected deep vein thrombosis. He also said that he was unhappy about the care and treatment Mrs C had received following her admission to Inverclyde Royal Hospital (the Hospital) and felt that the communication both to Mrs C, her family and between the Hospital staff had been inadequate.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) there was a delay in the initial diagnosis of Mrs C's condition (upheld);
- (b) the treatment given to Mrs C was inappropriate (partially upheld); and
- (c) there were significant failures of communication, concerning her treatment and care, both to Mrs C and her family and between the Hospital staff (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mr C and his family for the delay in diagnosis and share this report with the clinical staff responsible for Mrs C's care;
- (ii) review their pain assessment and management procedures and ensure that these include a full explanation of the role and involvement of specialist or palliative care teams in the care of patients with non-surgical pain;
- (iii) apologise to Mr C and his family for not fully explaining Mrs C's pain management regime and for any unnecessary pain that Mrs C suffered as a result of this;
- (iv) review their policies and procedures to ensure that there is suitable monitoring of nutritional care and management;
- (v) provide evidence that standards of communication have improved and, in particular, that there are policies and procedures in place to ensure that patients who are terminally ill and their families are fully supported and treated with appropriate dignity;
- (vi) emphasise to staff responsible for responding to complaints the importance of doing so in a non-defensive and open manner; and
- (vii) apologise to Mr C and his family for all the failures identified in record keeping and communication; for failing to provide adequate support to them and Mrs C during her final illness; for the confusion about the circumstances surrounding Mrs C's death; and for failing to respond with appropriate care and sensitivity to the concerns raised by Miss C on their behalf.
The Board have accepted the recommendations and will act on them accordingly.