Summary
Ms C, a support and advocacy worker, complained on behalf of Ms B about the care and treatment provided to Ms B's son (Mr A) when he was admitted to Balfour Hospital (the hospital) following a road traffic accident. Ms C said that when Mr A arrived at the hospital his spine was not x-rayed despite him reporting pain in his back, and that when Mr A was later transferred to another hospital it was found that he had a spinal fracture. Ms C also complained that a wound to Mr A's leg was not cleaned appropriately and said this led to infections.
We took advice from an emergency consultant and an orthopaedic surgeon. We found multiple significant failings in the care and treatment provided to Mr A. These included a failure to examine and x-ray Mr A's spine; a failure to obtain
x-rays of Mr A's neck, chest and pelvis; a failure to assess and clean a wound in Mr A's arm in a timely manner; a failure to administer antibiotics in a timely manner; and a failure to administer appropriate pain medication. We also found that the treatment provided was not appropriately documented in the medical records. However, we determined that Mr A's leg wound was appropriately cleaned and therefore did not uphold this aspect of Ms C's complaint.
We had further concerns that the board's own investigation into Ms C's complaint failed to identify the serious clinical failings in this case and made recommendation regarding this.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Ms C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) |
The Board failed to provide Mr A with appropriate clinical treatment in view of his presenting symptoms |
Provide a written apology to Ms B and Mr A for failing to provide Mr A with appropriate clinical treatment in view of his presenting symptoms. This apology should be copied to Ms C |
Copy of written apology which complies with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance By: 27 September 2017 |
We are asking the Board to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) |
There were a number of significant failings in Mr A's care, including failure to:
|
The Board should provide a reasonable standard of trauma care, with adequate staff training and effective systems in place to support this |
Evidence that the Board have carried out a significant event review in to this case, with the findings made available to Mr A's family By: 22 November 2017 Evidence that the Board has reviewed their systems and staff training for the initial management of seriously injured patients (including review of the competencies and training for consultants who are expected to lead the assessment and resuscitation of patients with major trauma) By: 22 November 2017 |
|
(a) |
The Board's own investigation did not identify or address the serious failings in the care provided to Mr A |
The Board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement |
Evidence that the Board have reviewed why its own investigation into the complaint did not identify the failings highlighted in this report By: 25 October 2017 |
|
(a) & (b) |
There was a failure to appropriately document the treatment provided in the medical records |
All treatment should be appropriately documented in medical records |
Documentary evidence that this finding, and what action will be taken to ensure medical records are adequate in the future, has been shared and discussed with relevant staff. This could include, for example, minutes of discussion at a staff meeting or copies of internal memos, emails or notes of feedback given about this complaint By: 27 September 2017 |