Overview
Mr C complained about the level of care provided to his daughter, Miss C, prior to her death in Ninewells Hospital, Dundee (the Hospital), on 1 April 2008. Miss C suffered from myotonic dystrophy, a condition in which generalised muscle weakness can be accompanied by a variety of other conditions, which in Miss C's case included learning difficulties. Miss C was admitted to the Hospital on 31 March 2008 for surgery on her parotid gland. Pre-operatively, she did not receive a formal assessment by a consultant anaesthetist. Post-operatively she was returned to the ward, where her initial observations included a period of low blood pressure. She was left to sleep overnight. Her vital signs were not recorded and she was not disturbed in the morning during a post-operative ward round. She was subsequently found to be unresponsive at around 10:30 and a cardiac arrest call was made at 10:58; however, it was not possible to resuscitate her. Her death was recorded at 11:17 that morning.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Miss C was not properly assessed at a formal pre-operative clinic prior to her surgery (upheld);
- (b) the care and treatment Miss C received post-operatively was inadequate (upheld); and
- (c) communications with Miss C's family were not appropriate (upheld).
Redress and recommendations
The Ombudsman recommends that Tayside NHS Board (the Board):
- (i) review the current interface arrangements in place between the ENT and Anaesthesia departments, to gain assurance that adequate communication, planning and multi team working arrangements are now in place with regard to pre-operative admissions; and advise him of the outcome of this review;
- (ii) provide a copy of the appropriate action plans which specifically contain details of how the Board will implement and meet the relevant policies, including: NHS QIS quality indicators for people with learning difficulties (NHS QIS report 'Learning Disabilities' Quality Indicators February 2004); NHS QIS report 'Tackling Indifference', (Healthcare Services for People with Learning Disabilities. National Overview Report. December 2009);
- (iii) provide a copy of their education and training strategy, including the specific requirement relating to patients with learning disabilities;
- (iv) review and evaluate the current arrangements for pre-operative admission for people with learning disabilities and provide him with a report of the findings;
- (v) confirm the specific action taken to clarify the terms 'special nursing' and 'routine monitoring' to avoid ambiguity over what level of nursing support is required when caring for people with learning difficulties;
- (vi) provide assurance that policies and procedures are in place to ensure that the Nursing and Midwifery Council Code of Conduct and in particular the 'Guidance for record keeping' (2009) is implemented so that communication with patients' families is clear and unambiguous; and
- (vii) provide an explicit, unambiguous and meaningful apology to Miss C's family for all the failings identified in this report, detailing the steps they have put into place to ensure that a similar occurrence is not repeated.
The Board have accepted the recommendations and will act on them accordingly.