Summary
Mrs C complained via an advocacy service in relation to her husband (Mr A) who was receiving end of life care at home. Mrs C had gone out one morning, expecting a visit from a district nurse (the nurse) to take place in her absence. When Mrs C returned, she found Mr A deceased and in an inappropriate position. Mrs C called her immediate family who lived within walking distance. Her daughter (Mrs B) covered Mr A up and the family contacted the emergency services.
Paramedics attended and confirmed that Mr A had died. A doctor from the family's GP practice attended to certify death. Mrs C complained to the board shortly afterwards, saying that she believed the nurse had left the property whilst Mr A was dying or after he was dead.
In response to the complaint the board conducted an internal investigation. They interviewed Mrs C, the nurse and other health professionals involved in the case. The nurse accepted that they had left the property without recording their visit properly, but stated they had intended to return. They denied strongly having left Mr A in an inappropriate condition.
The finding of the internal investigation was that the nurse's version of events was confused and contradictory. It concluded the nurse had breached professional guidelines in terms of record-keeping and that the care they had provided had fallen below an acceptable standard.
The internal investigation recommended a disciplinary hearing be held. Mrs C's advocate advised us that the family had not been kept informed of the board's actions. The advocate said there had been an extended and unexplained delay in the investigation and when a formal complaint was made about this, the board's complaint response was entirely inadequate.
The advocate said the family were told they could not be given any details of what had happened to Mr A, though they were told the board were satisfied that the nurse had responsibility for the condition Mr A was found in. We reviewed all the interviews and information considered by the board's internal investigation. We also interviewed Mrs B, who said she felt she had been overlooked by the board's original investigation. We took professional advice on the standard of nursing care provided to Mr A and whether this met the professional standard expected of a nurse. We found that although it was not possible to determine exactly what took place, the likelihood was that the nurse performed some form of treatment on Mr A.
There was no suggestion this had contributed to his death, but the weight of the evidence pointed to Mr A being left in an inappropriate condition by the nurse. We found the board's investigation had failed to interview family members, and that the board had not provided the family with an adequate explanation for their actions. The advice we received was that the nurse's actions fell below acceptable professional standards and that the care provided to Mr A was unreasonable.
Redress and recommendations
The Ombudsman recommends that the Board:
- consider a referral to the Nursing and Midwifery Council, in view of the concerns raised over the Nurse's conduct and that an explanation for any decision reached is provided to this office;
- review the procedures for the management of lone working in the community to ensure an adequate level of communication is sustained between staff and managers;
- remind staff of the importance of giving consideration to interviewing all individuals involved in an the incident under investigation;
- provide evidence that the actions identified in their review of the handling of Mrs C's complaint have been implemented;
- provide evidence that all staff have been reminded of the need to identify and record complaints accurately; and
- apologise unreservedly for the failings identified in this report.