Overview
The complainant, Ms C, raised a number of concerns that her late mother (Mrs A) had received inadequate medical post-operative care in her own home from her practice GP ( GP 1) and the District Nursing Service (the DNS), before Mrs A was re-admitted to a Dundee hospital (the Hospital) and subsequently died.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) GP 1 failed to re-refer Mrs A back to the Hospital when this was requested by a district nurse (no finding);
- (b) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to enter relevant details in case notes about Mrs A's condition (upheld); and
- (c) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to relay family concerns to the practice GPs (upheld).
Redress and recommendations
The Ombudsman recommends that:
- (i) GP 1 reflects on Adviser 1 and Adviser 2's comments (see paragraphs 17 to 21) and considers discussing these at her next appraisal;
- (ii) the fundamental standards of documentation are considered by the practice and the Board and revisited across the DNS as an outcome of complaints (b) and (c); and
- (iii) although the services within the complaint (the Board, the practice and the DNS) have demonstrated a willingness to deal with complaints and identify solutions, from the information reviewed, there is no evidence to suggest that any of the work/actions identified have fully addressed the fundamental areas of holistic assessment and communication between teams, or been referenced to any professional standards or guidelines in relation to the assessment process, documentation, communication, wound care, care planning and patient held records. Accordingly the Ombudsman recommends that these areas are explored and that she is advised of the outcome.
The Board and the Practice have accepted the recommendations, some have already been implemented and others will be acted on accordingly.