Overview
The complainant (Mr C) raised concerns about the care and treatment which his late wife (Mrs C), who had severe Multiple Sclerosis, received from Greater Glasgow and Clyde NHS Board (the Board) during her time in hospital for treatment of her painful right hip. Mr C complained that, whilst in hospital, the Board failed to feed his wife, who required to be fed via a percutaneous endoscopic gastrostomy tube, in a sufficiently upright position, which caused food to pass into her lungs. Mr C said he believed that the Board failed to notice that his wife had then developed a chest infection and provide necessary treatment and that this had resulted in her death.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board did not feed Mrs C in a sufficiently upright position (not upheld); and
- (b) the Board failed to notice that Mrs C had developed a chest infection and treat it in time (partially upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mr C for failing to notice that Mrs C had developed a chest infection on 16 February 2007 and provide appropriate treatment at that time and for failing to produce a care pathway for Mrs C when the course of her treatment changed;
- (ii) feed back the adviser 's views on what he considers would have been the appropriate course of treatment for Mrs C on 16 February 2007, to the staff involved in cases of this type and in Mrs C's care, in particular;
- (iii) provide training to staff to ensure that, in all appropriate cases, where the direction of a patient's treatment changes, a new care pathway is devised - this could be by introducing a multi-disciplinary record or audit of documentation;
- (iv) ensure the staff involved in Mrs C's care are made aware of the need to record accurate information on patient mobility in their records;
- (v) review their current policy on the use of special mattresses and beds, incorporating the NHS QIS standards and flowchart; and
- (vi) provide feedback to the staff involved in Mrs C's care on the importance of seeking guidance from a more senior member of the medical team on appropriate treatment and/or to ask technical staff for assistance, in cases where the accuracy of medical equipment, such as a pulse oximeter, is in question.