Overview
The complainant (Mr C) was unhappy with the care provided to his late wife (Mrs C) by Lothian NHS Board (the Board). Mrs C was admitted to the Royal Infirmary of Edinburgh (Hospital 1) on 18 August 2008, but was transferred to Liberton Hospital (Hospital 2) on 19 August 2008. She was given a course of antibiotics, but these were subsequently discontinued. Mrs C's condition deteriorated and she died in Hospital 2 on 26 August 2008.
Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:
- (a) provide appropriate treatment to Mrs C (upheld);
- (b) provide the correct course of antibiotics to Mrs C (upheld); and
- (c) communicate effectively with Mr C (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that their transfer protocol includes a requirement to consult with appropriate available relatives prior to transfer, when a patient is unable to give consent;
- (ii) provide guidance on documentation to all relevant staff at induction;
- (iii) adhere to their Incident Management Policy when a significant adverse event review is initiated, by ensuring that consideration is given to the inclusion of members with appropriate objectivity to the event;
- (iv) remind staff in Hospital 2 of the importance of assessing the competency of patients to make decisions to refuse treatment or medication where appropriate;
- (v) undertake an external peer review of the nursing care in Ward 1 in Hospital 2;
- (vi) provide him with details of the findings and action plan created as a result of the above recommendation and provide updates where relevant;
- (vii) ensure that the findings in this report are communicated to the staff involved in Mrs C's care and treatment; and
- (viii) issue an apology to Mr C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.