Overview
The Complainant (Miss C) complained on behalf of her friend (Mrs A) who underwent surgery for an inguinal hernia at the Western General Hospital in March 2010. Miss C raised concerns about delays to Mrs A's operation, which she felt could have been avoided. She also raised complaints about the service that Mrs A received from Lothian NHS Board (the Board) when she was in hospital.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Mrs A's operation was unnecessarily delayed (upheld);
- (b) Mrs A's special medical requirements were not made known to ward staff prior to her admission to Ward 23 (upheld);
- (c) cleanliness and staff hygiene practices in Ward 23 were poor (not upheld);
- (d) food service on the ward was poor (upheld);
- (e) the Board discharged Mrs A without ensuring that she had access to adequate support outwith the hospital (upheld); and
- (f) the Board's complaint handling was poor (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) share this report with the staff involved in Mrs A's care with a view to identifying any lessons that can be learned from her case;
- (ii) review their procedures for reporting CT scan results back to the referring clinician;
- (iii) review their procedures for tracking the progress of patients whose treatment has been referred to a different consultant;
- (iv) take steps to ensure that nursing staff maintain patient records in line with the Nursing and Midwifery Council's Record Keeping and Guidance for Nurses and Midwives;
- (v) take steps to satisfy themselves that the steady decline in the cleanliness monitoring score between September 2009 and March 2010 was not indicative of an endemic deterioration in cleanliness and hygiene standards on Ward 23; and
- (vi) provide training to staff on Ward 23 regarding nutrition, communication and record-keeping.
The Board have accepted the recommendations and will act upon them accordingly.