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Investigation Report 200503188

  • Report no:
    200503188
  • Date:
    February 2007
  • Body:
    Dumfries and Galloway NHS Board
  • Sector:
    Health

Overview

The complainant (Mr C) raised a number of concerns about his mother (Mrs A)'s treatment in Dumfries and Galloway Royal Infirmary prior to her death on 15 September 2005.

Specific complaints and conclusions

The complaints from Mr C which have been investigated are that:

  • (a)  on 13 September 2005 his mother was inappropriately admitted to an assessment ward when her condition was already known (upheld);
  • (b)  despite her agitated state and her family's request, she was not given any sedation or water (upheld); and
  • (c)  there was delay in releasing his mother's body for cremation (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

  • (i)       confirms the palliative care nurse's recommendations to her with a view to their early introduction;
  • (ii)      reinforce to nursing and medical staff the need for good assessment and evaluation for patients with pain and agitation and, to emphasise the importance of communicating to families;
  • (iii)      formally apologise to Mr C for their failure to provide  Mrs A with water and for the delay in re-evaluating her medication; and
  • (iv)      confirm their improved procedures concerning cremation forms and the date when they are introduced.

The Board have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018