Overview
The complainant (Mr C)'s father (Mr A) was admitted to Queen Margaret Hospital (the Hospital) after falling and breaking his left hip. Mr C raised a number of concerns relating to the care and treatment that Mr A received during his stay at the Hospital. He complained that Fife NHS Board (the Board) failed to maintain adequate standards of ward cleanliness, resulting in Mr A picking up two hospital-acquired infections. He also complained about the nursing care Mr A received, noting that his father had fallen four times whilst staying at the Hospital, on one occasion fracturing his right hip. Mr A died at the Hospital. Mr C raised further concerns regarding the Board's failure to contact his family in time for them to be with Mr A at the time of his death.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) there was a lack of care and compassion by the nursing staff on Ward 14 when Mr A fell four times (upheld);
- (b) there was a lack of cleanliness in Ward 14 (not upheld);
- (c) there was a lack of concern from nursing staff in Ward 20 when Mr A's family highlighted that his blood pressure reading appeared high (not upheld);
- (d) Mr A contracted MRSA twice (not upheld);
- (e) the Board failed to inform Mr A's family of the rapid decline in his clinical condition or to contact them prior to his death (upheld); and
- (f) the Board failed to remove a catheter tube from Mr A's body (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review the circumstances surrounding Mr A's falls with a view to identifying, and rectifying, underperformance in the practical implementation of their falls management and dementia care policies and procedures; and
- (ii) review the circumstances leading to Mr C's complaint and consider introducing measures to improve communication with patients' families.
The Board have accepted the recommendations and will act upon them accordingly.
Please note that this Report contained a typographical error in paragraph 2. It should read:
5 October 2009.