Overview
The complainant (Mrs C) raised a number of concerns regarding the care and treatment of her late mother (Mrs A) during an admission to Queen Margaret Hospital in Dunfermline (the Hospital) between 12 April 2010 and her death on 5 May 2010.
Specific complaints and conclusions
The complaints which have been investigated are that Fife NHS Board (the Board):
- (a) failed to continue with antibiotic treatment after the course of Amoxicillin (an antibiotic) was completed at 22:00 on 1 May 2010, despite Mrs A's rapidly deteriorating condition (upheld);
- (b) failed to act on the concerns Mrs C raised on 2 May 2010 (upheld);
- (c) were unaware that Mrs A was expectorating thick green sputum (matter coughed up from the lungs) on 1 May 2010, when this is documented in the medical records (upheld);
- (d) failed to inform Mrs C about Mrs A's deteriorating condition (upheld);
- (e) failed to ensure that oral medication administered to Mrs A when she was in a semi-conscious state did not remain in her mouth from 08:00 on 5 May 2010 until Mrs C pointed this out at 14:00 on 5 May 2010 (not upheld);
- (f) failed to provide an Incident Report regarding when Mrs A was inappropriately handled and spoken to (upheld);
- (g) failed to ensure complaint (f) was investigated (upheld);
- (h) disagreed about the cause of death after the Death Certificate was issued and registered (not upheld); and
- (i) made inconsistent statements in their original complaint response to those made at a face-to-face meeting - specifically about the presence of infection (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) provide me with an update regarding their implementation of the measures described in their letter to my office dated 24 March 2011;
- (ii) review the means by which the clinical judgements of HAN members who see patients independently are monitored;
- (iii) conduct a review of information handover from team to team, with a view to identifying how this can be strengthened;
- (iv) consider Adviser 2's comments on the failings in Mrs A's nursing care and draw up and implement an action plan to address these failings;
- (v) apologise to Mrs C for the failure to investigate complaint (f) properly;
- (vi) ensure that serious complaints are appropriately recorded and investigated;
- (vii) inform me of the outcome of their discussions with regard to completing death certificates and tell me what measures they have taken to ensure that, in future, the cause of death listed on a death certificate is accurate; and
- (viii) ensure that clinical records are thoroughly reviewed as part of their investigation process and prior to providing responses to complaints.
The Board have accepted the recommendations and will act on them accordingly.