Overview
The complainant (Mrs C) together with other members of her family raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) concerning the care and treatment their mother (Mrs A) received while a patient in the Victoria Infirmary, Glasgow between September and November 2010. Mrs A died in hospital on 13 November 2010.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the care and treatment provided to Mrs A, including the management of her pressure ulcer and the use of a Certificate of Incapacity, was inadequate (upheld);
- (b) the implementation and application of the Liverpool Care Pathway (LCP) was inadequate (not upheld); and
- (c) communication between board staff and Mrs A's family was unreasonably poor, in particular a meeting with Mrs A's Consultant on 26 October 2010, and a telephone conversation between Mrs A's son and a medical registrar on 1 October 2010 (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) provide the Ombudsman with evidence that the Board's current policies and procedures regarding the prevention, management, monitoring, education and training of pressure ulcers is in line with national guidance and best practice;
- (ii) take steps to put in place an action plan to address the shortcomings identified in this report in relation to pressure ulcer management and share this action plan with both the Ombudsman and Mrs C;
- (iii) review how in-patient units communicate with each other about the decision making capacity of patients requiring procedures as in-patients, to ensure that a patient who is being managed under the terms of the Adults With Incapacity (Scotland) Act 2000, is known to be so by any other team undertaking a procedure that would normally require written consent;
- (iv) consider whether the use of treatment plans (recommended for patients with complex care needs) might support the effective use and validity of Certificates of Incapacity in terms of Section 47 of the Adults With Incapacity (Scotland) Act 2000;
- (v) review how clinicians document the fact that capacity may be lacking for one specific intervention but present for other investigations and treatments if they believe this to be the case;
- (vi) ensure that family and carers are appropriately involved and informed of the consideration of use of the Adults With Incapacity legislation in the care of a patient and to document this clearly on the Certificate of Incapacity;
- (vii) apologise to Mrs C and other members of the family for the failings identified in complaint (a);
- (viii) with reference to our adviser's comments under paragraph 84 of this report, consider auditing the precise location of death of their in-patients and whether any system of prioritisation for single rooms across units might minimise this;
- (ix) seek to ensure that any discussion that a member of staff has with a patient's family is recorded in the patient's medical records; and
- (x) apologise to Mrs C and other members of the family for the failings identified in complaint (c).