Investigation Report 201102521

  • Report no:
    201102521
  • Date:
    December 2012
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:
    Health

Overview
The complainant (Mrs C) raised a number of concerns against Greater Glasgow and Clyde NHS Board (the Board) that her late father (Mr A) had been inappropriately cared for by nursing staff in Dunrod F Ravenscraig Hospital (the Hospital) from 2 February 2011 up to his death on 24 April 2011.

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

  • (a) nursing staff unreasonably failed to monitor and maintain Mr A's fluid levels (not upheld);
  • (b) nursing staff unreasonably failed to deal with incontinence issues (not upheld);
  • (c) nursing staff unreasonably failed to maintain a reasonable level of hygiene for Mr A (upheld);
  • (d) there were inadequate transfer systems and documentation in place (upheld);
  • (e) there was poor communication from staff (not upheld);
  • (f) nursing staff unreasonably failed to pass on information to the relevant Social Work team when Mr A was transferred and this delayed the process of establishing a suitable nursing home for him to go to (not upheld);
  • (g) inadequate attention was paid to Mr A's dignity by ensuring that his clothing was appropriately attended to (upheld); and
  • (h) the investigation of Mrs C's complaint to the Board was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) ensure that measures are taken to feed back the learning from this to nursing staff to avoid similar situations recurring;
  • (ii) provide him with an update on the actions they have taken to ensure such an incident does not recur;
  • (iii) ensure that communication between family members and staff are appropriately recorded;
  • (iv) ensure that measures are taken to feed back the learning from this to complaints investigation staff to avoid similar situations recurring; and
  • (v) apologise to Mrs C for the failures identified in this report.

 

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

Updated: December 11, 2018