Overview
The complainant (Mrs C) raised a number of concerns about the care given to her mother (Mrs A) at Perth Royal Infirmary (the Hospital) following her admission for a suspected oesophageal stent blockage on 9 August 2005.
Specific complains and conclusions
The complaints which have been investigated are that Tayside NHS Board (the Board):
- (a) prescribed morphine unnecessarily (no finding);
- (b) failed to provide appropriate nursing care (partially upheld);
- (c) failed to maintain accurate records (upheld); and
- (d) failed to provide an adequate complaint response (partially upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) emphasise to nursing staff in the relevant ward the importance of recording in the clinical records any change in the condition of the skin or injury and of ensuring that the commensurate care plan is also formulated and recorded;
- (ii) apologise to Mrs C for the confusion and distress caused by the apparently contradictory nature of some of the responses to her complaints;
- (iii) review the operation of the admission assessment and adopt a consistent process for recording alterations within the assessment;
- (iv) use the events of this complaint in a multi-disciplinary team meeting to illustrate the impact of poor complaint handling and record-keeping on the patient/carer experience; and
- (v) ask that those responsible for providing complaint responses ensure that, where possible, evidence, comment or information is obtained from and checked against, original sources.
The Board have accepted the recommendations and will act on them accordingly.