Overview
The complainant (Miss C) raised a number of concerns regarding the treatment her late mother (Mrs A) received at Wishaw General Hospital (the Hospital). Miss C was unhappy with the level of nursing care which Mrs A received, specifically in relation to a fall she suffered in the early hours of the morning following her admission. Miss C also raised concerns regarding numerous cancellations of the proposed surgery to address damage suffered to Mrs A's femur during her fall.
Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the standard of nursing care provided was inadequate (upheld); and
(b) the decisions to cancel surgery were unreasonable (not upheld).
Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board (the Board):
(i) undertake an urgent investigation into the nursing staff's failure to follow the correct procedure when administering a controlled substance;
(ii) implement an action to address the failure to assess Mrs A's pain, using the Modified Early Warning System tool;
(iii) implement a formal bed move policy which restricts any avoidable movement of vulnerable patients;
(iv) clarify their policy on nursing confused patients, providing a copy of a relevant risk assessment for patients' mental capacity, along with an appropriate nursing action plan, to be adopted following a diagnosis of confusion;
(v) remind staff of the importance of frequent vital observations, particularly after incidents where patients have sustained head injuries;
(vi) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in this report;
(vii) apologise to Miss C for the failings which have been identified in this report; and
(viii) ensure that a proper multi-disciplinary approach to patient care is in place and seen to be effective.
The Board have accepted the recommendations and will act on them accordingly.