Overview
The complainant (Ms C) raised a number of concerns about the care and treatment her late daughter (Miss A) received at Raigmore Hospital (Hospital 1). Miss A was seen by an out-of-hours GP at Hospital 1 and thereafter returned 24 hours later where she was admitted as her condition had seriously deteriorated. The following day, Miss A was transferred to the Royal Hospital for Sick Children in Edinburgh (Hospital 2) and sadly died two days later.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the receptionist failed to obtain appropriate assistance when Miss A presented at Accident and Emergency with soiled clothing (upheld);
- (b) Miss A was inappropriately discharged by the out-of-hours GP on 5 March 2011 (not upheld); and
- (c) staff failed to adequately monitor or provide timely treatment to Miss A when she was admitted to Accident and Emergency on 6 March 2011 (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) provide the Ombudsman with evidence to support that they have reviewed their gown supplies in Accident and Emergency and informed relevant staff of the procedure to follow when alternative clothing is required;
- (ii) remind the out-of-hours GP of the GMC's guidance in relation to record-keeping;
- (iii) draw to the attention of relevant staff the comments by Adviser 2 and Adviser 3 regarding documenting more detailed information on intubation in this case; and
- (iv) conduct a review of their Significant Event Analysis procedures to ensure that a detailed and robust investigation is carried out in all cases.