Overview
The complainant (Mr C) complained on behalf of himself and his family that Lothian NHS Board (the Board) failed to provide reasonable care and treatment to his wife (Mrs C) from 28 September 2007 to 15 January 2008. Mrs C was admitted to the Royal Infirmary of Edinburgh (Hospital 1) following a fall in September 2007. Mrs C suffered a fracture of her left ankle and a plaster cast was applied to her left leg. Mrs C subsequently had an above knee amputation of her left leg. Mr C did not consider this treatment was reasonable given Mrs C's other medical conditions. Mr C further complained that Mrs C contracted a Methicillin-resistant staphylococcus aureus (MRSA) infection while in Hospital 1 and about the overall standard of nursing care that Mrs C received. During the course of my investigation, I also included, as part of the investigation, the standard of record-keeping in respect of Mrs C's medical records.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the plaster cast that was applied to Mrs C's left leg was not appropriate treatment given Mrs C's other medical conditions (not upheld);
- (b) Mrs C contracted a MRSA infection whilst a patient in Hospital 1 (not upheld);
- (c) the standard of nursing care which Mrs C received was inadequate (not upheld); and
- (d) the standard of record-keeping in respect of Mrs C's medical notes was inadequate (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake a review of the policy for reviewing plaster casts and in particular referral to senior medical staff;
- (ii) encourage the doctor concerned to reflect on the case at their next appraisal;
- (iii) apologise to Mrs C and her family for the failing to review Mrs C's plaster cast which has been identified in head of complaint (a) of this report;
- (iv) provide the Ombudsman with copies of the next Scottish Patient Safety Programme audit documentation in relation to all patient records within the orthopaedics department of Hospital 1; and
- (v) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in head of complaint (d) of this report.
The Board have accepted the recommendations and will act on them accordingly.