Overview
The complainant (Mrs C) raised a number of concerns against Ayrshire and Arran NHS Board (the Board) regarding the care and treatment her late husband (Mr A) received at Crosshouse Hospital from his admission on 21 May 2010 up to his death on 23 May 2010.
Specific complaints and conclusions
The complaints which have been investigated are that the Board:
- (a) failed to administer the prescribed anti-seizure and steroid medication (upheld);
- (b) failed to recognise and address Mr A's pain (not upheld);
- (c) failed to implement the Liverpool Care Pathway until 23 May 2010 (not upheld); and
- (d) failed to provide adequate care and attention on the night of 22 to 23 May 2010 (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that measures are taken to feedback the learning from all aspects of this event to the medical team involved with Mr A's care, to understand the importance of avoiding similar situations recurring;
- (ii) review the process of pain scoring, its frequency and recording in this case and feedback the learning to nursing staff;
- (iii) complete a review of the LCP within the unit and feedback the learning to all medical and nursing staff within the unit;
- (iv) complete a full review of their medical staff cover for the night of 22 to 23 May 2010 to ensure such situations do not recur;
- (v) provide an update of their review on the use of pager numbers; and
- (vi) apologise to Mrs C for the failures identified in this report.
The Board have accepted the recommendations and will act on them accordingly.