Overview
The complainant, Mr C, raised a number of concerns about the care and treatment of his sister, Miss A, during an admission to Ninewells Hospital (the Hospital) in the 13 days leading up to her death. Mr C believed that had failures in Miss A's care and treatment not occurred, the outcome might have been different for her.
Specific complaints and conclusions
The complaints which have been investigated are that Tayside NHS Board (the Board):
- (a) failed to make an urgent and correct diagnosis of Miss A's condition when she was admitted to hospital (not upheld);
- (b) failed to provide urgent and appropriate treatment to Miss A (upheld);
- (c) failed in their duty of care towards Miss A (upheld);
- (d) failed to treat Miss A without delay due to holidays and staff not being available and, in particular, delayed in arranging a second Computerised Tomography scan (CT scan) (upheld);
- (e) might have saved Miss A's life had they not failed to provide her with urgent and appropriate treatment (not upheld);
- (f) stigmatised Miss A in relation to her alleged alcohol abuse and this affected the nature and urgency of the treatment she received (not upheld);
- (g) failed to explain to Mr C how the figure of 70 units of alcohol a week was noted as Miss A's alcohol intake on admission (not upheld);
- (h) failed to explain to Mr C why Miss A was unconscious during the first few days of her admission (upheld); and
- (i) failed to have a single doctor in charge of Miss A's care, which made communication with Mr C very difficult (upheld).
Redress and recommendations
The Ombudsman recommends that the Board inform ward staff and relatives of the named consultant in charge of a patient's care either in the form suggested by the Adviser at paragraph 56 or similar.
The Board have accepted my recommendation and will act on it accordingly.
I am also pleased that the Board, in response to my investigation, have repeated their apology to Mr C and his family for the failings in Miss A's care. I am also satisfied that the recommendations the Board put in place when initially responding to the complaint (see paragraphs 13 to 14 above) adequately address the central failings highlighted in complaints (b), (c) and (d), as they will ensure appropriate medical management and review and better care planning. It is unfortunate that, while the Board put appropriate recommendations in place in response to Mr C's complaint, they did not sufficiently acknowledge the nature and seriousness of the problems that occurred in this case when they wrote to Mr C. This has led to an unusual situation whereby the Board did not fully explain and acknowledge problems that occurred when responding to the complainant's complaint, but nevertheless put in place recommendations that, as it happens, adequately address the issues and failings that have been highlighted in this report. Consequently, while there have been serious failings in relation to Miss A's care and treatment, I have no recommendations regarding complaints (b), (c), and (d) because measures have already been taken by the Board that appropriately remedy the complaints.