Overview
The complainant (Miss C) raised a number of concerns that her sister (Ms A) had been provided with inadequate care and treatment in that the symptoms with which she was presenting between October and November 2011 were not appropriately investigated and treated.
A Critical Incident Review (CIR) of the events surrounding Ms A's care and treatment was held in May 2012 by Tayside NHS Board (the Board) following Ms A's death in April 2012. Miss C complained that the Board failed to provide the family with a copy of the CIR report despite repeated requests and failed to arrange a meeting with the family.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) between October and November 2011, staff at Ninewells Hospital failed to provide Ms A with appropriate medical treatment in view of the symptoms with which she presented (upheld); and
- (b) staff at the Board failed to provide the family with a copy of the CIR report despite them making repeated requests and failed to take steps to arrange a meeting with the family (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) provide evidence that appropriate action was taken to address the mis-reporting of the Magnetic Resonance Imaging scan of 10 October 2011;
- (ii) ensure that future Radiology Discrepancy and Complications Meetings are minuted and the minutes appropriately circulated;
- (iii) review the application of the 'three day guidance' to ensure that staff appropriately assess patients before referring back to their GP and where necessary provide refresher training;
- (iv) ensure that staff on the Acute Medical Unit are reminded of the need to be proactive in addressing patients pain;
- (v) continue to work towards producing a care pathway to improve the treatment of patients who present with un-resolving and/ or deteriorating symptoms, including improved communication with primary care providers (GPs);
- (vi) remind staff dealing with complaints about the usefulness of meetings at an early stage of the complaints process as per their Complaints Management Procedure; and
- (vii) issue a written apology to Ms A's family for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.