Overview
The complainant (Ms C) raised a number of complaints with Grampian NHS Board (the Board) about the care and treatment she received whilst being treated as an in-patient at Brodie Ward (the Ward) at the Royal Cornhill Hospital (the Hospital) in Aberdeen in 2010. She was dissatisfied by the Board's response to her complaints.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the care and treatment provided to Ms C on her admission to the Ward of the Hospital on 5 February 2010 was inadequate; (upheld)
- (b) the observations levels to which Ms C was subjected and the locking of the Ward door at night were inappropriate; (upheld)
- (c) there were communication issues during Ms C's stay on the Ward: including that she had difficulty in speaking to her named nurse; and that she was given inappropriate 'advice' on self-harming by a Staff Nurse (Staff Nurse 1); (upheld)
- (d) inadequate care and treatment was provided to Ms C after she took an overdose on 24 February 2010; (upheld)
- (e) it was unreasonable that on the occasions that Ms C expressed a desire to leave hospital she was 'threatened' with formal detention; (upheld)
- (f) the action taken following the incidents on 1 and 4 March 2010 was inappropriate and inadequate; (upheld)
- (g) staff on the Ward had an unreasonable approach to weight/body mass index (BMI) policy; (upheld) and
- (h) the Board unreasonably delayed in responding to the complaint made by Ms C on 25 May 2010. The Chief Executive did not respond until almost four months later on 6 September 2010. (upheld)
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) provide evidence to the Ombudsman that interim care plans are developed for patients on admission to the Ward, and that all appropriate documentation within patient records is being completed;
- (ii) develop a search policy to provide guidance to staff on the issues of patient dignity and safety;
- (iii) review their observation policy to take cognisance of the shortcomings identified, and ensure that the observation policy leaflet for patients is finalised and distributed to all patients on the Ward;
- (iv) review their policy in relation to door locking on the Ward at night to take into consideration the additional issues highlighted;
- (v) provide evidence to the Ombudsman of staff training in relation to communication with mental health patients, which should include guidance on ensuring professional and appropriate record-keeping by staff in relation to patients;
- (vi) develop a policy to reflect the Mental Welfare Commission's guidance in relation to short term detention, for staff use and guidance and ensure this is distributed to staff;
- (vii) undertake an audit to ensure incidents are being recorded appropriately on Datix;
- (viii) ensure staff are aware of their responsibilities in relation to patient confidentiality;
- (ix) develop policy for staff to advise of appropriate steps to take in relation to patient measurements, in conjunction with the Quality Improvement Scotland guidelines;
- (x) ensure that complainants are kept up to date in relation to the progress of their complaints, and are given full information about the options available to them;
- (xi) provide evidence to the Ombudsman that the Board operates a rights and values based approach in relation to the care of patients within the Adult Mental Health Directorate;
- (xii) draw this report to the attention of all the staff involved in Ms C's care; and
- (xiii) provide a full apology to Ms C for all of the failings identified within this report.
The Board have accepted the recommendations and will act on them accordingly.