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Mid Scotland and Fife
The account of the complaint provided by the complainant, referred to as Mr A in this report, is that he attended his local Medical Centre to be weighed by the Practice Nurse. Mr A required to be weighed before consideration could be given to providing him with a repeat prescription for Orlistat, which was to help him lose weight. While he was in the Practice Nurse’s room, the first GP entered the room and said that as he had not lost sufficient weight no repeat prescription would be issued. A discussion ensued during which the first GP, without provocation, used offensive and unprofessional language towards Mr A.
Tayside University Hospitals NHS Trust
Lanarkshire Primary Care NHS Trust
Tayside Primary Care NHS Trust
Summary
Ms C complained about the care and treatment provided to her late partner (Mr A) by their GP practice (the Practice) prior to his diagnosis of non-small-cell lung cancer stage 3 (advanced cancer).
Mr A had attended the Practice on a number of occasions during a five month period with symptoms of unresolving shoulder pain. Ms C said Mr A had seen a number of GPs during the period and that a request for a CT scan was refused initially. She also said that the GPs repeatedly prescribed painkillers which were ineffective. When Mr A was finally referred for a CT scan the diagnosis of cancer was made. Ms C felt that the failure of the GPs to refer Mr A for a CT scan had led to a delay in the diagnosis of cancer.
We took independent advice from a general practitioner, which we accepted.
We found that four of the six GPs involved in Mr A's care and treatment had failed to take appropriate action in an effort to determine the cause of Mr A's shoulder pain. Mr A's symptoms had not improved with different types of painkilling medication and after being referred for physiotherapy. A chest X-ray had been taken which was reported as normal. We found that the GPs had failed to consider the complete picture in that Mr A had attended the Practice on numerous occasions within a short timeframe and they dealt with the symptoms reported at the time of the consultations. They had not fully considered the previous consultations which would have allowed them to be better informed of the situation.
We also found that one of the GPs involved had incorrectly advised Mr A that he absolutely did not have cancer, which was an inaccurate statement to have made as at that stage a specialist opinion had not been obtained. This would have given Mr A false reassurance.
We also found that two of the GPs involved in Mr A's care took appropriate action when considering Mr A's reported symptoms and proposed reasonable investigations in an effort to reach a diagnosis.
We upheld Ms C's complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Practice to do for Ms C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
There was an unreasonable delay in referring Mr A for a specialist opinion in view of his presenting symptoms |
Apologise to Ms C for the failure to refer Mr A for a specialist opinion at an earlier stage |
A copy or record of the apology. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance By: 21 November 2018 |
We are asking the Practice to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
|
There was an unreasonable delay in referring Mr A for a specialist opinion in view of his presenting symptoms
Doctor 4 unreasonably gave Mr A an assurance that he definitely did not have lung cancer
|
All doctors at the Practice should be aware of the Scottish Cancer Referral Guidelines. Any doctors who were involved in the complaint and are no longer at the Practice should be made aware of and sent a copy of this report
Doctor 4 should be aware of the importance of accurate communication with patients in accordance with General Medical Council Good Medical Practice guidelines |
Evidence that the findings of this case have been used as a training tool for staff and that this decision has been shared and discussed with the relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails By: 21 November 2018 Evidence that doctor 4 has reflected on their actions and that the matter has been shared and discussed with them in a supportive manner. This could include minutes of discussions at a meeting or copies of internal memos/emails
By: 21 November 2018 |
Feedback
Points to note
As highlighted by the Adviser, the SPSO investigation notes there is evidence of good medical practice by Doctors 1 and 6 in that they took appropriate action when considering Mr A’s reported symptoms and proposed reasonable investigations in an effort to reach a diagnosis. In reflecting on this complaint, we strongly urge the Practice to share and learn from the positive aspects of the treatment.
Summary
Mrs C complained to me about the care and treatment she received from Lanarkshire NHS Board (the Board). Her concerns relate to the treatment she received following her operation to form a stoma (an opening in the stomach to divert bodily waste through so it can be collected in a bag).
Mrs C was admitted to Monklands Hospital (the Hospital) on a number of occasions after this operation, with on-going symptoms of nausea and stomach pain. In the last admission, Mrs C's small bowel perforated (a hole formed in it) and she developed sepsis (a severe complication of infection). Mrs C received emergency surgery from which she recovered, however, she developed neurological problems which have left her partially sighted and with a weakness down her left side. Mrs C raised concerns that there was a delay in recognising the seriousness of her condition and in performing surgery to treat it. Mrs C felt that if earlier action had been taken, she might not have developed these neurological problems.
We took independent advice from a general and colorectal surgeon, which we accepted.
We found that Mrs C had an incomplete small bowel obstruction (blockage) where the stoma was formed, caused by tissue swelling. We found that Mrs C's symptoms, her repeated admissions to the Hospital and the results of the investigations carried out were all suggestive of this. We considered it was unreasonable that the Board did not recognise this at the time. We also considered it was unreasonable Mrs C was not referred for surgery at an earlier point, particularly when her condition worsened. We concluded that if surgery had been carried out earlier, Mrs C would probably not have developed severe sepsis, which is the likely cause of her neurological problems. We were concerned that the Board's review did not identify any failings in the care provided to Mrs C.
We upheld Mrs C's complaint. We made a number of recommendations to address the issues identified. The Board have accepted the recommendations and will act on them accordingly. We will follow-up on these recommendations. The Board are asked to inform us of the steps that have been taken to implement these recommendations by the date specified. We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that the recommendations have been implemented.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
There were failings in diagnosing Mrs C's incomplete bowel obstruction and an unreasonable delay in referring her for surgery, despite her worsening condition |
Apologise to Mrs C for the failings in diagnosing and treating her incomplete bowel obstruction |
A copy or record of the apology. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance
By: 20 August 2018 |
We are asking the Board to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
|
There were failings in diagnosing Mrs C's incomplete bowel obstruction and an unreasonable delay in referring her for surgery, despite her worsening condition |
The results of hospital tests and investigations should be carefully reviewed and in similar cases, earlier surgical intervention should be considered |
Evidence that the findings of this case have been used as a training tool for staff and that this decision has been shared and discussed with relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails
By: 18 September 2018
|
| Mrs C's stoma activity and output was not properly assessed and/or documented during her admissions to the Hospital |
After a loop ileostomy, stoma activity and output should be clearly assessed and documented, as it is important for assessing the stoma and bowel function |
Evidence that this decision has been shared and discussed with relevant staff in a supportive manner. This could, for example, include minutes of discussions at a staff meeting or copies of internal memos/emails
By: 18 September 2018 |
| The Board's own investigation did not identify the significant failings in the care provided to Mrs C |
The Board's complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (where appropriate) |
Evidence that the Board have demonstrated learning from this case and complaints in general
By: 18 September 2018 |
Summary
Mrs C, who works for an advice and support agency, complained on behalf of Mrs B about the care and treatment provided to Mrs B's late father (Mr A) by Lanarkshire NHS Board at Hairmyres Hospital (the hospital). Mr A had diabetes and had been admitted to the hospital to have his leg amputated. Mrs C complained that his diabetes was not properly monitored or managed following the surgery. She said that this led to the development of diabetic ketoacidosis (DKA - a serious problem that can occur in people with diabetes if their body starts to run out of insulin). She also complained about the actions of nursing staff.
We took independent advice from three advisers: a consultant in acute medicine, a diabetes specialist nurse and a general nursing adviser. In relation to Mrs C's complaint that the Board did not provide reasonable treatment to Mr A, we found that there were a number of serious failings, which were that the board failed to:
- adequately monitor Mr A's blood glucose and respond to both hypo-glycaemia (low blood sugars) and hyper-glycaemia (this occurs when people with diabetes have too much sugar in their bloodstream);
- manage Mr A's diabetes and insulin administration in line with the board's protocol;
- recognise and respond in a timely manner to his deterioration; and
- recognise the possibility of heart problems whilst he was in the medical High Dependency Unit (HDU).
The advice we received also highlighted a number of other failings:
- When Mr A was transferred to the medical HDU overnight, he was not seen until the following morning. This was an unreasonable delay given the severity of his illness and the complexities of managing DKA in a patient with known cardiac problems (aortic stenosis – tightening of one of the valves in the heart and impairment of the heart as a muscle). This would have made providing the large quantities of fluid as part of DKA management potentially difficult.
- Mr A was transferred out of medical HDU despite signs that he was starting to deteriorate. There was then a delay in reviewing him when he was transferred back to the surgical ward. We found that Mr A should have subsequently been readmitted to medical HDU or to coronary care.
- Mr A should have had a review of his antibiotics during his second deterioration, as he had already been on his antibiotic regime for three days and would have probably needed different antibiotics and review of any microbiology results.
- There was a failure to measure/chart his respiratory rate when he was deteriorating.
In view of these failings, we upheld Mrs C's complaint that the board did not provide reasonable treatment to Mr A.
Mrs C also complained that the board did not provide reasonable nursing care to Mr A in the hospital. She said that nursing staff did not respond reasonably to alerts from another patient's visitors about Mr A's condition and that nursing staff did not reasonably record the actions they took in relation to this in Mr A's medical notes.
We found that the actions of a nurse when Mr A's condition deteriorated had been unacceptable and unreasonable. The nursing documentation in relation to this matter was also inadequate and we upheld this aspect of Mrs C's complaint.
Finally, Mrs C complained that the board did not respond reasonably to Mrs B when she complained to them about these issues. We upheld this aspect of the complaint, as the board failed to identify the serious failings referred to above. We considered that this was both unreasonable and that it called into question the adequacy of the board's complaints handling at the time.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs B:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) and (b) |
The Board did not provide Mr A with reasonable treatment. The nursing documentation in relation to the actions of the nurse when Mr A's condition deteriorated on 4 October 2016 was inadequate |
Apologise to Mrs B for failing to provide Mr A with reasonable treatment and for the inadequate nursing documentation. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology.
By: 25 May 2018 |
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) |
The Board failed to adequately monitor Mr A's blood glucose and respond to both hypo- and hyper-glycaemia |
The Board should reflect on the findings in this report and ensure patients with erratic blood glucose have their capillary blood glucose checked and recorded regularly and at a frequency appropriate to their specific circumstances and condition |
Evidence that relevant staff have been informed of this and that consideration has been given to any training requirements to support staff in carrying out these checks.
By: 25 July 2018 |
|
|
(a) |
The Board failed to manage Mr A's diabetes and insulin administration |
Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to diabetes management in hospital, including recognising diabetic emergencies and advice on who they can contact if they have concerns, including at the weekend |
Evidence that staff have the appropriate level of skill and access to guidance, support and training.
By: 25 July 2018 |
|
|
(a) |
There was a delay in reviewing Mr A when he was transferred to the medical HDU |
Admissions to the medical HDU should be seen on arrival by medical staff |
Evidence this matter has been considered and a decision taken to act (or not), that includes reasons for the decision.
By: 25 June 2018 |
|
|
(a) |
Staff failed to recognise the possibility that Mr A had heart problems in medical HDU on 5 October 2016 |
Medical HDU should ensure that electrocardiograms are routinely and appropriately reviewed for patients who have deteriorated or been admitted overnight |
Evidence that this matter has been considered and, where appropriate, action has been taken and any changes disseminated.
By: 25 June 2018 |
|
|
(a) |
Mr A was transferred out of the medical HDU on 6 October 2016, despite signs that he was starting to deteriorate |
Patients who are deteriorating should not be discharged from the medical HDU without a clear plan |
Evidence that this matter has been fed back to staff in a supportive way that encourages learning.
By: 25 June 2018 |
|
|
(a) |
There was a delay in recognising and starting treatment for possible sepsis |
Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to the consideration of sepsis and on reviewing antibiotics previously prescribed |
Evidence that staff have the appropriate level of skill and access to guidance, support and training.
By: 25 July 2018
|
|
|
(a) |
There was a delay in reviewing Mr A when he was transferred back to the surgical ward in the late afternoon of 6 October 2016 |
Patients who have been transferred out of a HDU environment to a general ward should be reviewed on arrival in the ward or as close to that time as possible |
Evidence that this matter has been considered and a decision taken to act (or not), that includes reasons for the decision.
By: 25 June 2018 |
|
|
(a) |
There was a failure to measure/chart Mr A's respiratory rate |
Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to early warning scores with regard to the importance of respiratory rate |
Evidence that staff have the appropriate level of skill and access to guidance, support and training.
By: 25 July 2018 |
|
|
(c) |
The Board's investigation into Mrs B's complaint failed to identify a large number of the failings we have referred to in this report |
The Board should reflect on the findings in this report and ensure that complaints are investigated appropriately |
Evidence that relevant staff have been informed of this and that consideration has been given to any training requirements to support staff in investigating complaints.
By: 25 July 2018 |
|
Summary
Mrs C complained about the care and treatment provided to her late husband (Mr C) by Fife NHS Board (the board). Mrs C's complaint related to delay in diagnosing that Mr C had lung cancer and the treatment provided to Mr C. Mrs C complained that the standard of care Mr C had received had been poor.
We took independent advice from a consultant respiratory physician. We found that Mr C was high risk for lung cancer, given his history as a former smoker with a background of heavy exposure to asbestos, and presenting with a cough and breathlessness. There were also concerning features in Mr C's radiology results and his case was complex. Despite this, Mr C was removed from an expedited cancer referral pathway without his case being discussed at a lung cancer multi-disciplinary team (MDT) meeting and without consideration given to a tissue biopsy being carried out. There was also no evidence that there had been any discussion with Mr C to enable him to make an informed decision about his future treatment. We also considered that that the board did not appear to have followed national standards and guidelines in Mr C's case.
The advice we received was that this represented serious failings in Mr C's care and treatment and that if such action had been taken, this could potentially have resulted in a different outcome for Mr C. As such, we upheld this complaint. The board have told us they now have systems and processes for patients in a similar situation to Mr C which they say are significantly different from what was previously in place and are willing to have their lung cancer service independently audited and peer reviewed. In view of the failings we identified, we made a number of recommendations to address this.
Mrs C also complained about the palliative nursing care Mr C received following his cancer diagnosis. We took independent nursing advice. We found that although the board had taken action following Mrs C's complaint, the advice we received was that there were serious failings in the nursing care provided to Mr C following his cancer diagnosis which had not been identified or addressed by the board. There had been a failure to comply with professional and clinical standards for practice which would be expected of the nursing staff and the palliative care provided had fallen below the standards which Mr C and his family should have reasonably expected. We upheld this complaint and made a number of recommendations to address the issues identified.
Mrs C also complained that the board's handling of her complaint was inadequate. We were satisfied there were failings in how the board responded to Mrs C's complaint and upheld this part of her complaint. We made recommendations to address these failings.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a), (b), (c) |
There were serious failings in diagnosing that Mr C had lung cancer and in the treatment he received. There were serious failings in the nursing care provided to Mr C after his cancer diagnosis in June 2015. There were failings in the Board's handling of Mrs C's complaint |
Apologise to Mrs C for the failings in: Mr C's diagnosis and treatment; the nursing care provided to Mr C after his cancer diagnosis in June 2015; and the handling of Mrs C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology By: 21 March 2018 |
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) |
Mr C was unreasonably removed from the expedited lung cancer referral pathway without his case being discussed at a lung MDT meeting, which led to a delay in diagnosing that he had lung cancer. This adversely impacted on Mr C's outcome |
Patients who present with suspected lung cancer symptoms should not be removed from the expedited lung cancer referral pathway without the case being discussed at a lung MDT meeting |
A copy of the current systems and processes in place on the removal of patients from the cancer referral pathway showing they take into account national guidance and the appropriate process for discussion at a lung MDT meeting. Evidence of the review of patients who were removed from the referral pathway in the same year as Mr C. Evidence that the Board has carried out an independent and impartial review of the lung cancer service which includes considering the appropriateness of any decision to remove a patient from the lung cancer care pathway without an MDT meeting being held. The evidence is to include providing SPSO with a briefing document outlining the scope of the review; who will be carrying out the review; and a report on the outcome of the review. Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning By: 21 August 2018 |
|
|
(a) |
There was a failure to involve Mr C in making an informed decision about his treatment |
Patients should be fully informed and involved in decisions about their treatment |
Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning By: 23 April 2018 |
|
|
(a) |
There was a failure to refer Mr C to a lung MDT meeting when cancer was diagnosed and it became apparent that the skin lesion was metastatic |
Patients should be appropriately referred to a MDT meeting. |
Evidence that patients are being appropriately referred for discussion at MDT meetings within the lung cancer service (this could be evidence provided as part of the audit referred to above) By: 23 April 2018 |
|
|
(b) |
Mr C and his family did not receive the standard of palliative nursing care and support which they should have reasonably expected to receive |
Patients who require palliative nursing care and their families should the receive care and support needed. This should be adequately led, co-ordinated and person-centred |
Details of a review of the Palliative Care Service with evidence that any training needs identified as part of the review are being met, or planned (with definitive timescales, not simply a broad intention). Evidence that this report has been shared with relevant staff and managers in a supportive way and that reflection and learning have taken place By: 23 April 2018 |
|
|
(b) |
There was a failure by nursing staff to comply with national guidance and standards; in particular, in relation to assessing and managing pain and distress; and maintaining care plans |
Nursing staff should ensure that national guidance and standards are adhered to; in particular, in relation to the assessment of pain and distress and managing care plans |
Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning By: 23 April 2018 |
|
|
(b) |
There was a failure to comply with NMC and Scottish Government requirements for prescribing |
The Board should ensure that systems are in place to ensure that nurse prescribing complies with NMC standards and Scottish Government guidance |
Details of the system in place (including procedures or instructions to staff) to ensure the safe prescribing of medicine by all non-medical prescribers which follows NMC and Scottish Government standards and guidance Evidence that the Board have reviewed whether relevant nursing staff have received sufficient training in the prescribing of medication, particularly to address the failings identified in this report and evidence of how training will be kept up to date By: 23 April 2018 |
|
| (b) | There were omissions in record-keeping in relation to the recording of nursing care provided to Mr C | Nursing records should be maintained in accordance with the nursing and midwifery code of practice and standards |
Evidence that the findings of this report have been shared with relevant staff and managers in a supportive way, and what action has been taken as a result. By: 23 April 2018 |
|
| (c) | The Board's handling of Mrs C's complaint fell below a reasonable standard | Staff should be aware of the importance of keeping complainants updated and providing a full response |
Evidence that the model CHP has been circulated with attention drawn to matters of particular relevance By: 23 April 2018 |
|
Evidence of action already taken
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
|
Complaint number |
What we found |
What the organisation say they have done |
Evidence SPSO needs to check that this has happened and deadline |
|
(c) |
The Board acknowledged that documents relating to a meeting about Mr C's case had not been located during the Board's investigation of Mrs C's complaint |
The Board had raised what had occurred with the department responsible and taken action to address how they stored health records; and they were also introducing a new electronic system during 2017 which will provide a single point for all patient information to be logged electronically |
Evidence, such as: discussions about what occurred; the changes that have been made; and revised procedures or instructions to staff about the storage of patient information records By: 23 April 2018 |
Summary
Mr C complained about the care and treatment his late wife (Mrs C) received from the Emergency Department at Monklands Hospital (the hospital) when she attended with abdominal pain. Mr C was concerned that Mrs C had been discharged home during the early hours of the morning without being assessed properly and that she was in pain.
We took independent advice from two clinical specialists, including a consultant in emergency medicine and a consultant in emergency general surgery. We considered that the clinical assessments and record-keeping by two different doctors who reviewed Mrs C fell below a reasonable standard. In addition, we found that there was no evidence to demonstrate that Mrs C had been offered pain relief despite it having been documented that she was experiencing moderate to severe pain.
We also found that a significantly abnormal blood test result had been overlooked by the board on three separate occasions: at the time Mrs C was discharged from hospital; when providing clinical information to the Crown Office and Procurator Fiscal Service's forensic pathologist; and when investigating Mr C's complaint. We considered that, had a more senior doctor overseen Mrs C's care, and due attention been given to this test result, she would have been admitted to hospital which may have avoided her death.
In terms of Mrs C being discharged home during the early hours of the morning, we considered this unreasonable given Mrs C was an elderly, frail woman with multiple health problems. We were critical that hospital staff did not communicate with Mr C about the discharge and that the paperwork which prompts such discussions had not been completed appropriately.
We upheld both complaints and made a number of recommendations to address the issues identified. The Board have accepted the recommendations.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) and (b) |
I found that there were unreasonable failings in Mrs C's care and in the Board's investigation of the complaints |
Provide a written apology to Mr C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at https:www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology By: 24 January 2018 |
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) |
The quality of the clinical assessments and documentation by both doctors was of an unreasonable standard |
Patients should receive a full assessment with all relevant information documented including: medical and medication history; and observations |
Confirmation that both doctors have been made aware of the findings and had the opportunity to discuss and learn from them, including reference to any learning and development, or training, identified By: 21 February 2018 |
|
(a) |
Staff failed to perform a 12-lead ECG. |
A 12-lead ECG should be used in the assessment of abdominal pain in similar cases |
Evidence that relevant staff have undertaken educational activities to better understand cardiovascular disease in women and what action to take in future By: 21 February 2018 |
|
(a) |
Mrs C's discharge from hospital was not overseen by a more senior doctor and an important blood test result was overlooked |
Patients should not be discharged without senior doctor oversight in similar cases. All relevant results should be taken into account |
Confirmation that Doctor 2 has been made aware of the findings and had the opportunity to discuss and learn from them, including reference to any learning and development, or training, identified By: 21 February 2018 |
|
(a) |
The Board failed to provide COPFS with the serum amylase test result |
All relevant test results should be identified and provided to COPFS |
Evidence that the Board have now sent this result to COPFS Evidence that staff have been reminded of the importance of providing all relevant information at the relevant time By: 21 February 2018 |
|
(a) and (b) |
The Board's investigation of the complaints was not robust and failed unreasonably to identify the abnormal serum amylase test result |
Clinicians providing input to complaint investigations should thoroughly review the care provided |
Evidence that these findings have been shared with Doctor 3 with appropriate support By: 21 February 2018 |
|
(b) |
It was unreasonable to discharge Mrs C without contacting Mr C in advance |
The discharge section of the clinical records should be completed in terms of relative/next of kin contact in all cases |
Evidence that the Board has a process in place for auditing discharge documentation Evidence that my decision has been shared with relevant staff with appropriate support By: 21 February 2018 |