Investigation Report 201100109

  • Report no:
    201100109
  • Date:
    April 2012
  • Body:
    Fife NHS Board
  • Sector:
    Health

Overview
The complainant (Mrs C) raised a number of concerns about the care, treatment and subsequent discharge of her husband (Mr C), who has dementia, following his admittance to the Accident and Emergency Department (the Department) of Victoria Hospital (the Hospital) on 6 January 2011.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) the care and treatment of Mr C in the Department on 6 January 2011 was not reasonable (upheld);
  • (b) the arrangements for Mrs C to deal with Mr C's personal hygiene in the Department were unreasonable (upheld);
  • (c) the time taken to admit Mr C to a ward from the Department was unreasonable (upheld);
  • (d) the responses to Mrs C's telephone calls to the Department for information about Mr C were unreasonable (upheld);
  • (e) the arrangements for Mr C's discharge on 7 January 2011 were unreasonable (upheld);
  • (f) Mrs C was not provided with reasonable information upon Mr C's discharge (upheld); and
  • (g) Mr C's mental health condition and Mrs C's role as his carer, next of kin and holder of power of attorney over him were not reasonably taken into account during his admission (upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) remind nursing staff within the Department of their responsibilities with regards to patients' personal hygiene and that it is not appropriate to rely on visitors to undertake this for them;
  • (ii) provide evidence to the Ombudsman that staff within the Department have undergone training in relation to the importance of good communication with patients and their families;
  • (iii) review their policy in relation to ensuring appropriate discharge arrangements for patients, taking into account any vulnerabilities and risk factors;
  • (iv) remind nursing staff of the importance of treating patients with dignity at all times;
  • (v) review their policy in relation to providing discharge information to patients with dementia and their relatives and carers as part of the implementation of Scotland's National Dementia Strategy;
  • (vi) provide evidence that, as part of the implementation of Scotland's National Dementia Strategy, staff within the Department and the Ward are given ongoing training in relation to the importance of acknowledging dementia and recognising the role of carers and next of kin; and
  • (vii) provide a full formal apology to Mr and Mrs C for all of the failings identified within this report.

 

The Board have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018