Overview
The complainant Mr C , was unhappy with the care provided to his late mother, Mrs A. Mrs A had been admitted to the Victoria Infirmary (the Hospital) following a fall. Shortly after her admission, the Hospital identified an outbreak of the winter vomiting virus in the ward to which Mrs A had been admitted (Ward A). While there, Mrs A was diagnosed with an infection and her condition deteriorated. Sadly, Mrs A died a few days after moving from Ward A to Ward B. Mr C said he was concerned about the care and treatment provided to Mrs A and that he and his family had been distressed by the way Mrs A had been cared for after it became clear she was unlikely to recover. He said Mrs A had been moved into an open ward (Ward B) and the curtains around her bed left open. Mr C also raised complaints about matters relating to the closure of Ward A and stated that the Hospital had failed to ensure the public was aware there was an outbreak of infection. He also said he had been concerned about the general level of hygiene in and around Ward A.
Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the care and treatment provided to Mrs A was inadequate (upheld);
(b) there was insufficient care taken by staff handling an outbreak of infection in Ward A (upheld);
(c) the level of hygiene in and around the ward was inadequate (no finding);
(d) there were significant failures in communication about the effect on Mrs A of the infection and the serious nature of Mrs A's condition (upheld);
(e) there was a failure to ensure Mrs A's dignity (upheld); and
(f) the Board did not respond appropriately to the complaint (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
(i) use a root cause analysis or similar tool to examine the reasons for the clinical failures identified in treating Mrs A’s diarrhoea and managing her fluid intake;
(ii) provide clear evidence over the next 12 months that the new policy on professional standards of record-keeping is having significant improvements on the quality of documentation;
(iii) provide the Ombudsman with evidence that the initiatives underway on infection control should prevent a recurrence of the failings identified in this report;
(iv) use this complaint as part of their own ongoing programmes to improve cleanliness and, in particular, consider how hygiene standards can be tracked and monitored and how visitors and patients can be encouraged to feel they can approach staff about any concerns they have;
(v) share with the Ombudsman the results of patient and staff surveys on communication over the next 12 months and the audit of communication following report 200600345 and any action taken as a result;
(vi) keep the Ombudsman informed of the progress of implementation of the Liverpool Care Pathway over the next 12 months;
(vii) provide evidence of the actions being taken to ensure individual patient dignity until the Hospital is closed;
(viii) ensure that guidance to complaint handling staff emphasises the need for full disclosure of relevant information; and
(ix) make a full, detailed apology to Mr C and his family for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly .