Overview
The complainant (Mrs C) complained about the care and treatment provided to her husband (Mr C) following his admission to the Royal Alexandra Vale of Leven Hospital (the Hospital). Mr C was 90 years old and was admitted because he was suffering pains in his legs; prior to his hospital admission he was living independently with no other immediate health concerns. Mr C developed pneumonia in hospital and while being treated for this developed diarrhoea, kidney failure, a pressure ulcer and severe oral thrush. Mr C subsequently died. Mrs C felt the Hospital staff's lack of timely action had contributed to Mr C's death.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) staff did not diagnose the cause of pain in Mr C's legs (not upheld);
- (b) staff did not reasonably respond to Mr C's dehydration (upheld);
- (c) there was an unreasonable delay in carrying out an x-ray or scan following the diagnosis of a chest infection on 25 March 2012 (not upheld);
- (d) staff did not reasonably respond to Mr C's complaints of pain in his back on 1 April 2012 (not upheld); and
- (e) staff did not reasonably respond to the development of thrush in Mr C's mouth (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) remind staff at the Hospital of the need to communicate with patients and their relatives and carers to ensure they are kept fully informed about their care and treatment, and of the importance of a proactive approach in this regard;
- (ii) conduct an audit to ensure the timely assessment of all acute admissions by consultant medical staff;
- (iii) review the implementation of the fluid balance chart policy, with an emphasis on the identification of the appropriate point for staff to escalate concerns to clinical staff;
- (iv) ensure junior medical staff at the Hospital receive full training on the management of elderly and acutely ill patients with the aim of preventing kidney failure;
- (v) conduct a significant incident review with regards to the period of care from 27 March to 3 April 2012;
- (vi) issue a reminder to all medical staff at the Hospital to ensure that nursing staff are given timely notice of changes to patients' medication;
- (vii) advise staff at the Hospital that, where possible, patients and their families and carers must be able to discuss care and treatment with a named point of contact within the medical team; and
- (viii) give a formal apology to Mrs C for the shortcomings identified in this report and for the distress she has suffered.
The Board have accepted the recommendations and will act on them accordingly.