Overview
The complainant (Mrs C) raised a number of concerns regarding the care and treatment of her husband (Mr C) during admissions to Glasgow Royal Infirmary (Hospital 1) in October 2004 and March 2005.
Specific complaints and conclusions
The complaints which have been investigated are that Greater Glasgow and Clyde NHS Board (the Board):
- (a) failed to store medication appropriately and supervise drug-taking (upheld);
- (b) told Mrs C that failure to administer Warfarin was the cause of Mr C's stroke and Mrs C believed that the alleged failures relating to the storage of Mr C's drugs and supervision of his drug-taking between 4 and 6 October 2004 might have contributed to the stroke (partially upheld to the extent that there were failures in monitoring Mr C's INR during the admission);
- (c) inappropriately discharged Mr C too soon (not upheld);
- (d) failed to notice that Mr C was suffering from constipation while in hospital (upheld);
- (e) failed to provide any home help to Mrs C after her husband was discharged from hospital (no finding); and
- (f) failed to investigate Mrs C's complaint in a timely fashion or respond to all the points raised and adhere to NHS complaints guidelines and failed to clarify why the complaint was responded to from the complaints team at Stobhill Hospital (Hospital 2) rather than at Hospital 1 (partially upheld to the extent that the Board failed to respond to the complaint within the timescale required in NHS complaints guidelines and did not respond to all the points raised).
As the investigation progressed, I identified issues concerning Mr C's clinical records and his post-operative management. I, therefore, informed the Board and Mrs C that the investigation would additionally consider the following points:
- (g) Mr C's discharge summary dated 26 October 2004 included details about another patient (upheld); and
- (h) the Board failed to carry out Mr C's post-operative management appropriately from 2 March 2005 onwards (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mr C and Mrs C for their failure to monitor Mr C's bowel movements and for any discomfort or pain he would have suffered as a result;
- (ii) write to Mrs C repeating the apologies they have provided to me regarding their failure to handle her complaint properly;
- (iii) put measures in place to ensure that meaningful medical records are made on a daily basis;
- (iv) put measures in place to ensure that when investigations are carried out they are recorded and the results documented and where there are abnormalities, entries in the medical records should acknowledge them and record medical staff's intentions regarding them;
- (v) monitor and audit the effectiveness of the measures taken as a result of recommendations (iii) and (iv);
- (vi) consider Adviser 2's comments about the management of anaemia and review their practice with advice from, for example, a physician in charge of elderly patients. This review should lead to an agreed policy being formulated, which should particularly be directed towards post-operative care; and
- (vii) regularly review patients' medications so that inappropriate treatments are noted and, if necessary, stopped.
The Board have accepted the recommendations and will act on them accordingly.