Investigation Report 201204933

  • Report no:
    201204933
  • Date:
    January 2014
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Overview
The complainant (Mrs C) complained on behalf of her mother (Mrs A) to Grampian NHS Board (the Board) about the care and treatment her father (Mr A) received while a patient in Aberdeen Royal Infirmary (the Hospital) from 5 August to 23 September 2012.  Mr A had been admitted to the Hospital's Acute Stroke Unit after suffering a stroke at home.  Mr A died in the Hospital on 23 September 2012.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • Mr A's medical care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld); and
  • Mr A's nursing care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • draw this report to the attention of all senior medical staff involved in Mr A's care;
  • take steps to put in place an action plan to address the failings identified in this report;
  • ensure that staff document relevant discussions they have with a patient's family or their carer;
  • act upon the comments of Adviser 1 in relation to the introduction of a policy on the certification of a patient's death;
  • draw to the attention of relevant staff, the importance of providing evidenced based complaints responses;
  • share with relevant nursing staff the comments of Adviser 2 with regard to maintaining a patient's dignity;
  • draw to the attention of relevant staff, Adviser 2's concerns about the Board's rationale for removing Mr A's pyjama bottoms; and
  • apologise to Mrs A and her family for the failings identified in complaints (a) and (b).

The Board have accepted the recommendations and will act on them accordingly.

Updated: December 11, 2018