Overview
The complainant (Mr C) raised a number of concerns against Highland NHS Board (the Board) regarding the care and treatment his late father (Mr A) received from Dr MacKinnon Memorial Hospital, Broadford. Mr C stated that the Board failed to provide adequate care and treatment for Mr A from 31 May 2010 up to his death on 4 June 2010.
Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:
- (a) treat Mr A's constipation and subsequent complications appropriately (upheld); and
- (b) communicate effectively with Mr A, Mr C and Mrs C (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that treatment is initiated by clinical staff in good time when a patient's condition deteriorates and appropriate details of this are recorded in their medical notes;
- (ii) ensure that all relevant clinical details are recorded legibly by all doctors in the medical notes as and when they have reviewed a patient;
- (iii) ensure that staff consider the reasons for abrupt changes in patients, to ensure that reasonable action is taken to limit the chances of further problems developing;
- (iv) ensure that admission forms include prompts which assess a patient's cognitive function or capacity to participate in decision making;
- (v) ensure that nursing admission notes are completed appropriately for every patient;
- (vi) ensure that when a patient displays uncharacteristic behaviour, appropriate and timely cognisance is taken of this and any subsequent action required is recorded;
- (vii) ensure that measures are taken to feed back the learning from this event to all staff, to ensure that similar situations will not recur;
- (viii) conduct a review of end-of-life care, with specific reference to completion of Do Not Resuscitate forms;
- (ix) ensure that DNAR discussions with family members are documented; and
- (x) issue Mr C with a full and sincere apology for the failings identified in this complaint.
The Board have accepted the recommendations and will act on them accordingly.