Overview
Mrs C raised a number of serious concerns about the failure of staff at Ninewells Hospital (the to diagnose and treat her husband when he was admitted with heart failure. Mr C died within 24 hours of being admitted to the Hospital. Mrs C also raised a concern about a change in Mr C's medication shortly before his death. A final complaint concerned the time taken by the Board to respond to Mrs C's complaint and the failure to fully address her concerns.
Specific complaints and conclusions
The complaints which have been investigated are:
- (a) failure to diagnose and provide treatment for Mr C's heart failure (upheld);
- (b) inappropriate change in medication (not upheld); and
- (c) failure in complaint handling (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake a review of the operation and knowledge of the two Chest Pain Protocols at the Hospital and consider the adoption of a single unified protocol;
- (ii) review the events in this complaint at an MAU multi-disciplinary meeting to ensure lessons are learned from the failure to recognise the seriousness of Mr C's condition and to react promptly and appropriately to his deterioration;
- (iii) apologise in writing to Mrs C for their failure to provide an adequate or timely response to her complaint; and
- (iv) ensure that their complaints handling process both acknowledges any errors identified and uses these to drive service improvement.
The Board have accepted the recommendations and will act on them accordingly.