Overview
The complainant (Mr C) raised a number of concerns regarding the care and treatment received by his late wife (Mrs C) at Wishaw General Hospital (the Hospital), in the area of Lanarkshire NHS Board (the Board). Mrs C was admitted to the Hospital on the evening of 14 January 2008 with a perforated ulcer, having been sent home from Accident and Emergency (A&E) earlier that day with an incorrect diagnosis of gallstones. Thereafter, Mrs C remained in the Hospital where she passed away on 25 April 2008.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the recorded primary cause of Mrs C's death was inaccurate (upheld);
- (b) Mrs C's Alzheimer's was managed inappropriately and she was not treated with respect (upheld);
- (c) Mrs C's nutrition and oral care were managed inappropriately (upheld); and
- (d) Mrs C's perforated ulcer should have been diagnosed earlier and her initial discharge from A&E was inappropriate (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review Mrs C's death certificate in light of the discrepancy with the discharge letter and give the family a definitive answer;
- (ii) undertake an external review of nursing care in the wards on which Mrs C was treated following her release from intensive care. The review should consider the following: treatment of Adults with Incapacity, including the assessment of ability to consent and administration of medication; and the use of bank and agency staff;
- (iii) clarify how their papers/standards 'Caring and Compassionate Practice' and 'Top Tips in caring for People with Dementia' are being monitored and measured, and how the education and training is being rolled out;
- (iv) provide evidence regarding the implementation of the national policy for Senior Charge Nurses ('Leading Better Care');
- (v) ensure that there are systems in place for assisting patients with feeding, as outlined in the NHS Quality Improvement Scotland 'Food Fluid and Nutritional Care in Hospitals' standards;
- (vi) ensure that there are systems in place for the provision of oral hygiene, including policies and procedures; education and training and audits;
- (vii) remind staff of the importance of detailed record-keeping, particularly in relation to doctors' recognition and appreciation of any abnormalities;
- (viii) remind complaint handling staff of the importance of providing an accurate response to complaints and, where possible, a detailed explanation of events; and
- (ix) apologise to Mr C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.