Overview
The complainant (Mrs C) raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) regarding the care and treatment her father (Mr A) received while a patient in Glasgow Royal Infirmary (the Hospital). Mr A died in hospital on 26 November 2013.
Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:
- provide reasonable care and treatment to Mr A between 25 October and 26 November 2013 (upheld);
- communicate reasonably with Mr A's family between 25 October and 26 November 2013 (upheld); and
- respond reasonably to Mrs C's complaints about these matters (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- ensure its policies set out clear responsibilities for clinicians to ensure that tests are either reviewed by the requesting doctor, or handed over to colleagues;
- carry out a morbidity and mortality case review of Mr A's death. The review should include the actions of the Haematology and Orthopaedic departments and provide evidence that the following points were addressed: the handover procedures followed by medical staff; the care and treatment pathways for the management of patients who fracture their hip whilst on a geriatric ward; the failure to ensure that Do Not Attempt Cardio-Pulmonary Resuscitation was discussed appropriately with the patient or his family; whether the Board's end of life care policies were properly followed; whether Mr A's mental capacity was properly assessed and what procedure should have been followed; review whether there was appropriate and timeous discussion of resuscitation with Mr A's family; review the failure to document in Mr A's records the reason for his ward transfer; review the lack of early Consultant input into case discussions with Mr A or his family;
- include the findings of the morbidity and mortality review in the subsequent appraisal of the consultant responsible for Mr A's care;
- remind all staff of the importance of documenting and signing discussions with patients' families;
- apologise for the failings identified in this report; and
- provide evidence that the actions referred to in the complaint response letter have been implemented.
The Board have accepted the recommendations and will act on them accordingly.