Overview
The complainant, Ms C, raised a number of concerns about the care and treatment provided to her mother, Mrs A, in the Vale of Leven Hospital (Hospital 1) between 26 August 2004 and 6 September 2004. Mrs A was subsequently admitted to Gartnavel General Hospital (Hospital 2) on 10 September 2004 but, sadly, died on 19 September 2004.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) a renal ultrasound scan was not performed on admission to Hospital 1 and when one was done at Hospital 2 the results were not acted upon (upheld);
- (b) communication with Consultant 2 at Hospital 2 was inadequate (upheld);
- (c) Mrs A was inappropriately noted as having 'no medical issues' when allowed home on weekend pass (upheld);
- (d) Mrs A was discharged from Hospital 1 without appropriate action (upheld); and
- (e) the discharge letter was inadequate (upheld).
Redress and recommendations
The Ombudsman recommends that:
- (i) this case be discussed urgently with Consultant 1 and formally recorded at her next annual appraisal;
- (ii) the clinical team responsible for Mrs A's care in Hospital 1 consider and act on the lessons to be learned as a result of the failings identified in this report;
- (iii) Greater Glasgow and Clyde NHS Board (the Board) remind staff of the need for accurate records to be kept;
- (iv) the Board share with the Ombudsman a copy of the regular audit of communications which is presented to the NHS Board's Clinical Governance Committee; and
- (v) the Board apologise fully and formally to Ms C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.