Overview
The complainant (Mrs C) raised concerns that staff failed to monitor her son (Mr A) following an operation and that when his condition deteriorated they failed to telephone her although staff had been advised of current contact numbers.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) staff failed to monitor Mr A appropriately following the operation (partially upheld);
- (b) staff did not take adequate action to inform Mrs C that Mr A''s condition had deteriorated (upheld); and
- (c) staff hid in Mr A's room and watched television (no finding).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake an audit of the standards of record keeping on Ward 15 and review whether there is a training requirement to make staff aware of the role of the Diabetes and Gastroenterology specialist nurses;. The Ombudsman further recommends that in view of the poor standard of documentation, that the Board implements a strategy to monitor and review patient dependency levels and nurse staffing in order that the quality of nursing records do not suffer as a result of a disparity in patient cohorts
- (ii) adopt a process to ensure that current contact details are recorded accurately on admission and in particular that when a patient is transferred, that the details are reviewed. Secondly that the Board ensures that communication with carers (when a patient’s condition deteriorates) is raised with staff as being a key and integral aspect of documentationremind staff to ensure that current contact details are easily identifiable in clinical records particularly when patients are transferred from one area to another; and; and
- (iii) adopts a process by which the nurses allocated to a patient’s care on each shift are easily identifiable within the records and that any discussion with those staff as a result of a complaint are routinely documented.
The Board have accepted the recommendations and will act on them accordingly.