Overview
The complainant (Miss C) raised a number of concerns about the nursing care which her grandmother (Mrs A) received in Wishaw General Hospital (the Hospital), the nursing staff's management of her grandmother's diabetes, the communication between nursing staff and the Hospital Emergency Care Team (HECT), the communication between nursing staff and the family, the fact that information was missing from her grandmother's medical records and the fact that the wrong cause of death was recorded on her grandmother's death certificate.
The Board carried out an investigation into Mrs A's care and devised an action plan to remedy most of their failings, for which I commend them. I have, however, upheld all of Miss C's complaints principally because the Board did not apologise to Mrs A's family for any of their failings. An appropriate apology is an important part of remedying a failing and I am disappointed that the Board did not apologise despite recognising that aspects of Mrs A's care had been inadequate.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) nursing staff's communication with Miss C and her family about Mrs A's health was inadequate (upheld to the extent that no apology was given);
- (b) erroneous information was given to Miss C and her family about the cause of Mrs A's death and, additionally, that the wrong cause of death was recorded on Mrs A's death certificate (upheld);
- (c) nursing care and conduct were inadequate (upheld to the extent that no apology was given);
- (d) nursing staff failed to adequately manage Mrs A's diabetes (upheld to the extent that no apology was given);
- (e) nursing staff's communication with the HECT did not convey the urgency of Mrs A's situation (upheld); and
- (f) information was missing from medical records (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) issue an apology to Mrs A's family for staff's failure to adequately explain Mrs A's medical condition to them;
- (ii) apologise to Mrs A's family for the distress and inconvenience caused by the fact that they recorded the wrong cause of death on Mrs A's death certificate;
- (iii) take steps to ensure that the correct cause of death is recorded on a patient's death certificate;
- (iv) issue an apology to Mrs A's family for the poor standard of nursing care received by Mrs A in the Hospital;
- (v) apologise to Mrs A's family for their failure to adequately manage Mrs A's diabetes;
- (vi) apologise to Mrs A's family for nursing staff's failure to convey the urgency of Mrs A's condition to HECT;
- (vii) issue an apology to Mrs A's family for their failure to record all of the necessary information in Mrs A's medical records;
- (viii) remind relevant staff of the importance of recording important patient data accurately; and
- (ix) consider how best to improve communication between healthcare professionals, especially via the telephone.
The Board have accepted the recommendations and will act on them accordingly.