Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late husband (Mr C) by Ayrshire and Arran NHS Board (the Board) between June 2011 and August 2011. Mr C, who was 80 years old, was admitted to Crosshouse Hospital (the Hospital) on three occasions during this period after breaking his hip. He had type 2 diabetes, hypertension, ischaemic heart disease and urinary incontinence and was on a number of medications before the series of admissions. He was finally discharged home on 8 August 2011, but died eight days later.
Specific complaints and conclusions
The complaints which have been investigated are that staff at the Hospital:
(a) failed to appropriately assess Mr C’s complex medical conditions (upheld);
(b) wrongly decided to withhold Mr C’s numerous types of medication and failed to keep his medication under review (upheld); and
(c) failed to provide Mr C’s GP with sufficient and timely information about his condition on discharge from hospital (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
(i) review their policies and procedures for patients with diabetes admitted to non-specialist wards to ensure that adequate systems in the management of their care are in place;
(ii) issue a reminder to the relevant staff involved in MrC's care of the requirement to: keep clear, accurate and legible records; promptly provide or arrange suitable advice, investigations or treatment where necessary; consult colleagues where appropriate; and, refer a patient to another practitioner when this serves the patient’s needs;
(iii) make the relevant staff involved in Mr C's care aware of our finding in relation to the failure to keep the decision to stop his medication under review;
(iv) remind the relevant staff involved in Mr C's care that when an episode of care is completed, they should tell a patient’s GP about: changes to their medicines; the length of intended treatment; monitoring requirements; and any new allergies or adverse reactions identified; and
(v) issue a written apology to Mrs C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.