Overview
The complainant (Mr C) raised a number of concerns that his mother in law (Mrs A) had been inappropriately cared for in Perth Royal Infirmary. Mrs A had been admitted on 15 February 2013, with a sudden loss of mobility. She was discharged on 13 May 2013, but had not regained the ability to walk. Mr C said that it was not until later that the family learned Mrs A had suffered a fractured hip. Mr C said this was not properly diagnosed or treated and that Mrs A was never x-rayed during her stay in hospital. Mr C was also unhappy with the way his complaints were handled by Tayside NHS Board (the Board), as he felt the internal review process lacked objectivity and dismissed the family's concerns.
Specific complaints and conclusions
The complaints which have been investigated are that:
- the Board provided inadequate care and treatment to Mrs A (upheld);
- the Board's reviews of Mrs A's care and treatment were inadequate (upheld); and
- the Board's handling of and response to Mr C's complaints was inadequate (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- remind all staff of the importance of discussing completion of the Do Not Attempt Cardio-Pulmonary Resuscitation form with either the patient or appropriate family members;
- review their processes to provide a failsafe to ensure that vulnerable patients are fully assessed to determine their capacity;
- remind all staff involved in geriatric care of the importance of considering hip fracture in elderly patients with loss of mobility;
- review their procedures to ensure that internal case reviews have objective clinical assessment of the available evidence;
- review their procedures to ensure that where additional medical opinion is required, this is obtained in a formal statement from the clinician;
- review its complaints procedure to ensure that all meetings with complainants are formally noted;
- review its complaints procedure to ensure that complainants are provided with notes of all meetings with Board staff conducted under the complaints procedure; and
- apologise in writing to Mr C for the failure to diagnose Mrs A timeously with a hip fracture and for the identified failures in dealing with his complaint.
The Board have accepted the recommendations and will act on them accordingly.