Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment of her late mother (Mrs A) during an admission to Monklands Hospital (the Hospital) between 5 April 2005 and 26 June 2005.
Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Lanarkshire NHS Board (the Board) inappropriately refused to admit Mrs A to the Hospital on 4 April 2005 (not upheld);
(b) two doctors were rude to Mrs A when they saw her in Accident and Emergency on 5 April 2005 (not upheld);
(c) the Board failed to supervise Mrs A when going to the toilet and did not do enough to prevent her from falling over (upheld);
(d) the Board failed to ensure that Mrs A was eating and failed to consider nasal tube feeding (not upheld);
(e) the Board failed to supervise Mrs A's drug-taking, failed to correctly record drug-taking and failed to ensure that the right medication was given to the right patient (partially upheld to the extent that the Board failed to supervise Mrs A's drug-taking and failed to ensure that the right medicine was given to the right person);
(f) the Board failed to introduce a care package for Mrs A despite promises to do so and refused to allow Mrs C to take Mrs A home in the last few days of her life (not upheld);
(g) the Board failed to diagnose and treat an infection that Mrs A contracted while in the Hospital, which led to additional discomfort and pain and which Mrs A's family believe contributed to her death (not upheld);
(h) the Board failed to record sepsis as a cause of death on the death certificate (not upheld);
(i) the Board failed to carry out a post-mortem even though Mrs A had died sooner than expected (not upheld);
(j) the Board did not provide sufficient nursing care to Mrs A and did not help bring Mrs A's temperature down or remove her teeth and only checked up on her occasionally (upheld);
(k) the Board's nursing staff were unable to fit a syringe driver because a nurse was on her break (not upheld);
(l) a physiotherapist said that she could not help Mrs A because she was not co-operating, which was inappropriate (not upheld);
(m) nursing staff did not inform Mrs C or her brother that Mrs A was dying when they re-entered the room Mrs A was in (not upheld);
(n) no attempt at resuscitation was made and the family were not asked if they wanted it (not upheld);
(o) an empty syringe driver contributed to Mrs A's death (not upheld);
(p) Mrs A had to wait a long time on both occasions when a doctor was called on 26 June 2005 (not upheld); and
(q) the clinical records were inadequate, because they contained no observations for 25 June 2005 and no fluid charts (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
(i) emphasise to staff the importance of adjusting care plans in line with risk assessments, especially in relation to supervision needs, and ensure that staff fully understand the importance of, and the procedure for, incident reporting;
(ii) ensure that measures are put in place to monitor compliance with the Medicines Code of Practice;
(iii) reflect on this complaint and consider whether guidance or training is needed to ensure that patients' families feel appropriately supported when they decide to take an active role in caring for a relative; and
(iv) put measures in place to ensure that, where appropriate, fluid charts are filled out for patients and observations are recorded.
The Board have accepted the recommendations and will act on them accordingly.