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Investigation Report 200500103

  • Report no:
    200500103
  • Date:
    March 2007
  • Body:
    Argyll and Clyde NHS Board
  • Sector:
    Health

Overview

On 12 April 2005 the Ombudsman received a complaint from Mr C and his sister (Ms C) that Argyll and Clyde NHS Board (the Board) failed to provide their father (Mr A) with adequate clinical care and treatment at the Accident and Emergency Department (A&E) at the Inverclyde Royal Hospital (the Hospital) during his admission following a fall on 29 April 2004.  It should be noted that on 1 April 2006, Greater Glasgow and Clyde NHS Board took over responsibility for the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

  • (a) the Board failed to provide adequate clinical care and treatment to Mr A within the A&E Department (not upheld);
  • (b) the Board failed to provide adequate nursing care to Mr A within the A&E Department (upheld);
  • (c) the nursing notes were not adequate (upheld); and
  • (d) the Board failed to handle Mr and Ms C's complaints adequately (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

  • (i) perform a full audit of A&E nursing records in the next three months and provide the Ombudsman's office with the results of this audit;
  • (ii) take further action to ensure that the failings in the nursing documentation and communication my investigation identified are addressed, and that the Board provide the Ombudsman's office with details of who will take responsibility for this, and what action will be taken;
  • (iii) provide evidence of educational programmes and systems of competency- based measurement for A&E nursing staff in relation to triage performance, record-keeping, nursing assessment, care planning and discharge planning;
  • (iv) review their complaints handling; and
  • (v) write to Mr and Ms C to apologise for the Board's failure to address their concerns satisfactorily.

 

The Board have accepted my recommendations and are already acting on them.

 

 

Updated: December 11, 2018