Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment her late father (Mr A) received from Ninewells Hospital (the Hospital) after he was admitted on 20 April 2008 with collapse and expressive dysphasia (difficulty in using language). Mrs C is also aggrieved about the length of time it took for Tayside NHS Board (the Board) to respond to her complaints.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) there was inadequate monitoring of blood pressure (upheld);
- (b) there was lack of intervention to increase blood pressure (upheld);
- (c) the reintroduction of blood pressure and cardiac medications all at once was inappropriate (not upheld);
- (d) there was a delay in the swallow assessment and nasogastric tube being inserted (not upheld); and
- (e) there was a delay in the Board responding to the complaint (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review its policy regarding the monitoring of patients with acute stroke who are given treatment that may cause unexpected and precipitous falls in blood pressure;
- (ii) provide ongoing evidence, such as Scottish patient safety reports, which demonstrates consistency and continuity of care for those patients being transferred between wards or units; and
- (iii) review the need for a protocol in the stroke unit regarding the immediate management of patients with acute stroke who suffer sudden, severe and symptomatic falls in blood pressure.
The Board have accepted the recommendations and will act on them accordingly