Overview
The complainant (Mr C) raised a number of concerns that his father (Mr A) had received inadequate treatment while he was a patient at Ninewells Hospital (the Hospital).
Specific complaints and conclusions
The complaints which have been investigated are that there was:
- (a) inadequate treatment for Mr A's pressure sores (upheld);
- (b) inadequate monitoring of Mr A's pressure sores (upheld); and
- (c) an inappropriate decision to continue with a course of treatment for Mr A's pressure sores (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) provide evidence of a robust standard for records and record-keeping and provide evidence of measures that are in place to audit this area of practice;
- (ii) provide evidence that there is a programme of formalised education and training of the staff on Ward 11 with reference to the transfer of patients which includes the importance of effective communication and proactive nursing in relation to this process;
- (iii) provide assurances that they have a robust policy in place regarding inter-ward transfers;
- (iv) devise a quality assurance system whereby all patients suffering from pressure sores have care plans which are sufficiently detailed and also highlight the monitoring arrangements for the patient;
- (v) apologise to Mr A for the failings which have been identified; and
- (vi) reiterate to all relevant staff at the Hospital the importance of clearly recording the factors which lead to a decision regarding continuing or changing treatment.
The Board have accepted the recommendations and will act on them accordingly.