Overview
Ms C complained about the care and treatment provided to her father, Mr A, in the Royal Dundee Liff Hospital.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) it was incorrectly stated in Mr A's clinical records that he had been discharged from the Royal Victoria Hospital because he was unmanageable (upheld);
- (b) there was a delay in diagnosing a sub-dural haemorrhage (upheld);
- (c) Mr A's stick was taken from him inappropriately and no further mobility assessment was done (not upheld);
- (d) Mr A was over-sedated (not upheld);
- (e) there was a failure to diagnose a pseudo-obstruction (upheld);
- (f) a restraint was used unnecessarily (not upheld);
- (g) a restraint was used inappropriately (upheld); and
- (h) there was an unexplained delay in transferring Mr A to Ninewells Hospital (upheld).
Redress and recommendations
The Ombudsman recommends that:
- (i) the Board remind staff of the need to ensure that entries in clinical records are appropriate;
- (ii) the Board remind staff of the need for clinical records to be updated each time a patient is seen by a doctor;
- (iii) the Senior House Officers (SHOs) involved in Mr A's care raise the issue of record-keeping at their next appraisals;
- (iv) the SHOs involved in Mr A's care raise the issue of failure to diagnose the return of pseudo-obstruction at their next appraisals;
- (v) the Board develop and implement a policy on the use of restraints at the Hospital in line with Mental Welfare Commission guidelines;
- (vi) the Board include patient and family communication as an item to be appraised in the regular appraisals on trainee doctors carried out by Educational Supervisors (Consultants) and, for nursing staff, that the Board demonstrate that communication has a high priority in the supervision of trainee nurses and is included in the programme for any review of nursing standards; and
- (vii) the Board apologise to Ms C for the failures identified in this report.
The Board have accepted the recommendations and will act on them accordingly.