Overview
The complainant (Mrs C) raised a number of concerns about the information provided to her about the extent of her late husband (Mr C)'s ill health and the operation of a Do Not Resuscitate (DNR) order. Mrs C was also concerned about the adequacy of steps taken to protect Mr C in hospital.
Specific complaints and conclusions
The complaints which have been investigated are that Fife NHS Board (the Board) failed to:
(a) communicate adequately with Mrs C and in particular failed to follow the procedure for instituting and implementing a DNR order (upheld); and
(b) keep Mr C safe using appropriate restraint (partially upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
(i) review the DNR policy, the use, and value added by the use of, the resuscitation box in the Unitary Patient Record; followed by an ongoing audit (or similar improvement methodology) to ensure that there is clarity about when the policy applies and whether it is sustained in practice. The audit should measure the completion of the DNR form and associated documentation in the patient record;
(ii) review how Cardio Pulmonary Resuscitation status is communicated at ward level, to ensure nursing staff are aware of the importance of robust communication at handover and transfer. The national 'Leading Better Care' policy may be helpful here;
(iii) consider including DNR orders in both induction and Basic Life Support staff training. This is already done in some parts of NHS Scotland and is endorsed by the Scottish Palliative Care Society;
(iv) review the mechanisms in place to ensure that communication between patients, their relatives and carers and staff is recognised as an important part of the patient experience; and
(v) develop a specific policy for the WanderGuard bracelet to ensure that its use complies with the Adults with Incapacity (Scotland) Act 2000 to ensure patients are treated with dignity and respect.
The Board have accepted the recommendations and will act on them accordingly.