Overview
The complainant (Mrs C) had concerns about some aspects of communication at the Western Infirmary, Glasgow (the Hospital), and about their decision to transfer her 84-year-old husband (Mr C) to a hospital near his home in England. When Mr C was being transferred by ambulance from the WesternHospital Infirmary to the English hospital, his condition worsened, and she complained that the ambulance crew continued the journey, instead of stopping at another hospital on the way. He died in the English hospital a few days later.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) communication with the family and care at the GlHasgow hospital wereere inadequate (not upheld);
- (b) the ambulance crew's decision to continue the journey was inappropriate (not upheld but recommendations made for the Health Board and for the Scottish Ambulance Service);
- (c) the ambulance crew's record- keeping lacked detail (upheld);
- (d) the Glasgow hHospital should have operated (not upheld); and
- (e) the Glasgow hHospital should not have allowed the ambulance journey (not upheld).
Redress and recommendations
The Ombudsman recommends that:
- (i) the Health Board ensure that, where appropriate, 'Do Not Attempt Resuscitation' orders (DNARs) are communicated clearly, in writing, for ambulance crews and receiving hospitals;
- (ii) the Scottish Ambulance Service ensure that, where appropriate, ambulance crews obtain formal written DNAR information from referring hospitals; and
- (iii) the Scottish Ambulance Service ensure that record- keeping by ambulance crews during journeys is adequate.
The Board and the Scottish Ambulance Service have accepted the recommendations and will act on them accordingly.