Investigation Report 200503079

  • Report no:
    200503079
  • Date:
    September 2007
  • Body:
    Argyll and Clyde NHS Board
  • Sector:
    Health

Overview

The complainant (Mrs C) raised concerns about the nursing care received by her late husband (Mr C) in Lorn and Islands District General Hospital (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

  • (a)  Mr C’s medication for Parkinson’s disease was not correctly administered in relation to his PEG feeding (not upheld);
  • (b)  Mr C’s PEG tube was not properly cleaned by nursing staff so as to avoid blockage (no finding);
  • (c)  Mr C was not kept satisfactorily hydrated (not upheld);
  • (d)  Mr C’s feet were not kept elevated when he was sitting in his chair and this resulted in the formation of blisters on his heels (upheld);
  • (e)  Mr C was not given adequate physiotherapy in hospital (not upheld);
  • (f)  Mr C was not given access to his own oral suction machine and oral suction was not performed sufficiently frequently by staff (no finding);
  • (g)  Mr C’s torso and head were not kept elevated when he was in bed (upheld); and
  • (h)  Mr C was wrongly assessed as fit for discharge as he died shortly later (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

  • (i)  take steps to ensure that relatives are given appropriate information where treatment given in hospital is different from at home;
  • (ii)  apologise to Mrs C for their failure to appropriately manage Mr C’s pressure areas; and
  • (iii)  remind relevant staff to be attentive to any physiotherapy advice given on positioning a patient.  Furthermore, the Board should apologise to Mrs C for their failure to return Mr C to an upright position after a positional change.

The Board have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018