North East Scotland

Summary

C complained about the care and treatment their spouse (A) received while undergoing kidney dialysis in Aberdeen Royal Infirmary (the Hospital). A had progressive kidney failure, and had an arteriovenous fistula formed in anticipation of complete kidney failure. A fistula requires surgery to join an artery to a vein so that blood goes directly into the vein rather than going down to the small blood vessels of the hand before returning. If successful, the vein becomes larger and “tougher” which allows needles to be inserted three times a week to circulate blood out of the body to a dialysis machine.

A was admitted to Aberdeen Royal Infirmary with worsening symptoms attributed to severe kidney failure, with the intention of starting dialysis using the fistula. During dialysis treatment three days later, A started to lose blood from the needle insertion site. Staff attempted to control the bleeding but were unable to and sought assistance from medical staff. The vascular surgery team attended and were able to stitch the bleeding vessel, which stopped further blood loss, but A’s condition deteriorated and clinical staff were unable to stabilise them. A died of a myocardial infarction (heart attack) at 20:00 that evening. C complained that assistance was not sought quickly enough by staff working in the dialysis room. They complained that there was a delay in stitching A’s arm.

We took independent advice from a consultant nephrologist (the Adviser). The Adviser noted A’s complex medical history. They had advanced chronic kidney disease and focal segmental glomerular sclerosis (FSGS, a disease of the kidneys usually diagnosed by kidney biopsy), among other medical conditions, and were prescribed a range of medication including warfarin (an anti-coagulant, or blood thinner, used to treat or prevent blood clots) for atrial fibrillation (an abnormal or rapid heart rate, occurring when the heart’s upper and lower chambers beat out of coordination). A was also on aspirin which may increase bleeding risk by its effect on platelets, key to blood clotting.

We found a number of failings in A’s care and treatment. Medicines reconciliation on A’s admission failed to pick up a recent dose change in warfarin, resulting in A being given a higher dose than they had been prescribed by their GP. There was insufficient monitoring of International Normalised Ratio (INR, a measure of how long it takes the blood to clot used to determine the effects of anticoagulants on the clotting system). The Adviser told us that A’s admission to hospital, recent decline in functional status, elevated C-reactive protein (CRP, inflammation marker), low albumin (a protein produced by the liver that circulates in blood plasma and temperature) were all triggers for more frequent monitoring. Additionally, A was on aspirin, which in combination increases the bleeding risk.

We found that a number of individual risk factors and errors combined to cause profound bleeding and death. The confusion surrounding warfarin dosing and insufficient INR monitoring were significant in causing such extensive bleeding. Other warning signs, which may or may not have contributed to A’s death, were not noticed and considered by the medical team. The lack of escalation of A’s blood loss meant that time was lost before clinical staff attended.

Grampian NHS Board (the Board)’s response and learning focused on warfarin prescription and monitoring. We saw no evidence of changes of practice or policy regarding fistula bleeds. We found that staff did not have a clear escalation policy of when and whom to call when they were unable to control the bleeding.

These deficiencies in care contributed to A’s death, which we found was entirely preventable.

In conclusion, we found that the Board’s care and treatment fell below a reasonable standard, and we upheld C’s complaint.

We also found that the Board failed to investigate C’s complaint appropriately or adequately. It took several enquiries before the Board provided all the information we were asking for. We noted that statements of certain members of staff were obtained by the Board in response to our enquiry, rather than during the Board’s own investigation which was when we would have expected them to be taken. There were also some records which were only provided to us after the Board had received our draft report, which impeded our investigation process. All the relevant information should have been reviewed in the course of the Board’s original investigation, then provided to this office in response to our initial enquiry.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

We are asking the Board to improve the way they do things:

We are asking the Board to improve their complaints handling:

Summary

Mrs C complained to me about the care and treatment that her mother (Mrs A) received from Tayside NHS Board (the Board). In May 2017, Mrs A was diagnosed with renal cell carcinoma (a type of kidney cancer) and she was referred for kidney surgery to treat it. Following her kidney surgery in August 2017, Mrs A developed excess fluid around her lungs and an infection; and her condition continued to worsen. In late September 2017, Mrs A was discharged home for end of life care and she died the next day. 

Mrs C complained that the Board failed to provide Mrs A with reasonable clinical care and treatment in relation to her kidney surgery. We took independent advice from a consultant urologist (a clinician who treats disorders of the urinary system). We found that the decision to refer Mrs A for kidney surgery was unreasonable. We found there was a low risk the renal cell carcinoma would harm Mrs A; and she was at exceptionally high-risk from kidney surgery.

Mrs C also complained that the Board failed to give Mrs A reasonable care and treatment in response to her worsening condition after her kidney surgery. We found there was an unreasonable delay in recognising Mrs A had a haemothorax (a collection of blood in the lung cavity) but it was then treated appropriately.

Mrs C raised concerns that the Board failed to provide Mrs A with reasonable nursing care. We took independent nursing advice. We found a number of failings in Mrs A's nursing care in relation to the prevention of pressure ulcers (an injury to the skin and underlying tissue, usually caused by prolonged pressure), diabetes management and nutritional care.

Mrs C complained about Mrs A being discharged home for end of life care without appropriate pain relief. We found Mrs A was not prescribed enough hours of pain relief medication; and she should have been given a syringe driver (a machine that delivers continuous pain relief medication), as otherwise a carer would have had to give her hourly injections. 

Mrs C raised concerns about the Board's communication with Mrs A and her family about her condition and treatment. The Board acknowledged inadequacies in their communication; and we found that their communication was unreasonable overall. We found that the Board had appropriately apologised to Mrs C for this and we asked them to provide us with evidence of the action they had taken to address this.

We upheld all aspects of 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:

We are asking the Board to improve the way they do things:

We are asking the Board to improve their complaints handling:

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened.

Summary

Mr C complained to me about Grampian NHS Board (the Board)'s failure to assess and treat him for adult attention deficit hyperactivity disorder (ADHD - a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness).

In 2018, Mr C felt he was struggling to lead a balanced life and having difficulties coping within society. Mr C asked his GP about getting referred to the Board for an ADHD assessment. Mr C was told that due to service pressure, the Board had decided not to carry out adult ADHD assessments. When we made enquiries with the Board, we found that they had made that decision in 2015.

We took independent advice from a consultant psychiatrist, which we accepted. We found that the Board had unreasonably failed to provide Mr C with access to diagnostic services and treatment for ADHD. We found the Board's overall approach to adult ADHD assessments was unreasonable, as they should have assessed adults presenting with ADHD on a case-by-case basis. We also found that their approach was not in keeping with the relevant clinical guidance or the Scottish Government's mental health strategy that was in place at the time. We found that this had led to a service gap in diagnosing and treating adults with ADHD over an extensive period of time. We were critical that although the Board had acknowledged this to Mr C, they failed to take urgent action to address it and the impact it had on him. We were also critical of the explanation the Board gave to Mr C for taking this approach.

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 Mr C:

We are asking the Board to improve the way they do things:

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:

Summary

Mrs C, an advocacy worker, complained to me, on behalf of Ms A, about the care and treatment that Tayside NHS Board (the Board) provided to Ms A.

From early 2012 onwards, Ms A experienced severe hip pain following her right hip replacement surgery. It affected her ability to walk and to carry out everyday tasks. Despite various orthopaedic reviews and investigations over the following five years, no underlying cause was identified for her pain. In mid-2017, Ms A's symptoms suddenly worsened and she experienced total right hip replacement failure. Ms A was referred for further surgery and a deep-seated infection was found in her right hip joint. Mrs C complained about an unreasonable delay in diagnosing Ms A's hip infection.

We took independent advice from a consultant orthopaedic surgeon, which we accepted. We found that there was a failure to properly investigate Ms A for a hip infection over a period of five years, in light of her symptoms. We found that concerning and obvious changes were apparent to Ms A's hip in her x-rays taken in 2015, 2016 and 2017. However, these changes were missed in her orthopaedic reviews. We found that when the changes in her 2017 x-rays were subsequently identified, there was an unreasonable delay in offering her an orthopaedics review as she waited over three months to be seen. We were critical that the Board's investigation did not identify and/or acknowledge the significant failings in the care provided to Ms A.

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 Ms A:

We are asking the Board to improve the way they do things:

We are asking the Board to improve their complaints handling:

Feedback

Points to note:

Included in the advice I received and accepted were the following points from the Adviser:

• a clinical audit facilitator regularly reviewed Ms A and checked her blood metal ion levels.  This was appropriate and it was in line with the relevant Medicines and Healthcare Products Regulatory Agency (MHRA) guidance on metal-on-metal hip replacements.
• an MRI scan in 2012 was not a helpful investigation if a metal artefact reduction sequence (MARS) type of MRI scan was not available.
• after Ms A's hip replacement failed in August 2017, she was given entirely reasonable treatment by the Board.

Summary

Mrs C complained about the care and treatment given by Grampian NHS Board (the Board) to her late mother (Mrs A) during the period after she had a coronary artery bypass graft (a surgical procedure to treat coronary heart disease) and an aortic (heart) valve replacement in December 2016, until her death in March 2017.

Mrs A had a history of type 2 diabetes and after her operation she experienced significant delirium and a stroke. Her leg wound also broke down and became infected. Because of her changing and deteriorating symptoms, Mrs A moved on a number of occasions between Aberdeen Royal Infirmary (ARI) and Woodend Hospital. Regrettably, Mrs A’s condition deteriorated and she died in March 2017.

Mrs C was unhappy with Mrs A’s care and treatment and complained to the Board. They said that her case had been a complex one and that although her outcome had been poor, Mrs A had been treated by appropriate specialists and that management decisions made at each stage of her illness appeared to have been reasonable.

We took independent advice from a consultant geriatrician and from a registered nurse specialising in tissue viability. We found that while she was in ARI some of Mrs A’s post-operative problems could have been expected in someone with her complex health and overall frailty. However, insufficient attention had been paid to her symptoms of delirium in relation to her more surgical complications despite them causing Mrs A significant distress. We also found that the Board’s own pressure ulcer prevention and management pathway had not been followed; there were delays in referring Mrs A to the tissue viability team, her wounds were not attended to frequently enough and inappropriate dressings were used.

While we found that Mrs A’s medical care improved when she was initially transferred from ARI to Woodend Hospital for rehabilitation and more attention was paid to her delirium, the nursing care of her leg wound remained extremely poor and caused Mrs A pain and distress which were all avoidable.

Finally, we found that there had been a lack of information given to the family by ARI about Mrs A’s delirium and little to no evidence of discussion between nursing staff and the family. This was an extremely distressing time for Mrs A which was compounded by a lack of information.

We upheld Mrs C’s complaints and made a number of recommendations to address the failings identified.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

We are asking the Board to improve the way they do things:

We are asking The Board to improve their complaints handling:

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received from Grampian NHS Board (the Board).  Following his GP referral to the Board, Mr A was diagnosed with kidney cancer.  He had surgery to remove part of his kidney, which appeared to have removed all of the cancer.  However, around two years later, it was found that Mr A's kidney cancer had returned.  He was referred for further surgery to remove the rest of his kidney, which was then cancelled.  When Mr  A attended oncology (cancer specialists) to discuss other treatment options, he was told his cancer was terminal and it had spread more widely than previously identified.  Sadly, Mr A died early the next year.

Mrs C complained about a delay in first diagnosing and treating Mr A's kidney cancer.  She also complained about a delay in diagnosing and treating Mr A's kidney cancer when it returned and spread to other areas of his body.  Mrs C raised particular concerns that there was a delay in advising them of the seriousness of Mr A's condition. 

We took independent advice from a consultant urologist and a consultant radiologist, which we accepted.  We found that there was an unreasonable delay in diagnosing Mr A's kidney cancer, as his first GP referral was not actioned by the Board.  We found there was also an unreasonable delay in diagnosing that Mr A's kidney cancer had returned and spread.  This was due, in part, to a series of failings in interpreting the results of Mr A's scans.  We also found significant failings in the communication with Mr A about his condition and its seriousness.

Mrs C was also unhappy with how the Board dealt with her complaint.  We found that there was an unreasonable delay in dealing with Mrs C's complaint.  We also found the Board failed to thoroughly investigate or address all of Mrs C's concerns.  We were very concerned that the Board's review failed to identify or acknowledge the significant failings in their communication with Mr A and his family.

We upheld Mrs C's complaints.  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:

We are asking the Board to improve the way they do things:

We are asking The Board to improve their complaints handling:

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:

Feedback

Points to note:

Adviser 2 explained that it would have been best practice for the reporting radiologist to make a direct referral to the MDT in 2014.  However, they might not have been aware of the local process to do so because they were working remotely for a private company.  The Board might wish to make private companies aware of the local process for radiologists to make direct MDT referrals.

Adviser 1 noted that Mr A waited four weeks to be told about his kidney cancer, after his diagnosis was confirmed by the January 2014 CT scan and his treatment was discussed by the MDT.  The Board might wish to consider if it is possible to streamline this process so patients are offered earlier urology appointments in similar circumstances.

Adviser 1 considered that the Board could have written to Mr A about the histology findings at the same time as they wrote to his GP.  The Board might wish to consider copying patients into these types of GP letters in future.

Adviser 2 commented that the use of standardised CT protocols would make it easier to compare any follow-up CT scans with previous CT scans.  The Board might wish to carry out a review of CT protocols to ensure that optimum diagnostic quality imaging is obtained across the whole range of clinical scenarios or possible pathologies.

Summary

Mr C complained on behalf of his late mother (Mrs A) about the care and treatment she received from the Board.  Mr C and his father (Mr B) complained that there was an unreasonable delay diagnosing that Mrs A had bowel cancer.  In relation to an admission at Woodend Hospital towards the end of Mrs A’s life, Mr C complained that the nursing care was unreasonable and that there was an unreasonable delay diagnosing internal bleeding.

We took independent advice from a consultant gastroenterologist, a registered nurse and a consultant geriatrician. 

In relation to Mr C’s complaint about delay in diagnosis of cancer, we found that inadequate investigations were carried out.  We concluded that if the relevant clinical guidance regarding investigations had been followed, then Mrs A’s cancer would have been diagnosed in 2013 rather than 2016.  We noted that a number of failings contributed to the delay, including a failure to review the quality of previous investigations performed. 

We concluded that the failings in the investigation of Mrs A’s bowel symptoms likely had a significant impact on her ability to survive her illness.  In addition to this, we also concluded that it was likely that with correct treatment Mrs A would not have had prolonged and profound anaemia and may not have developed a myocardial infarction.  Finally, we were critical of the Board’s investigation of the complaint and concluded that they had failed to provide a full and accurate response to the family. We upheld this complaint.

Following surgery in Aberdeen Royal Infirmary to remove a tumour in her bowel, Mrs A was transferred to Woodend Hospital for a period of rehabilitation.  Mr C raised a number of concerns about the nursing care Mrs A received at Woodend Hospital.  We found a number of failings in the nursing care Mrs A received during this admission.  We were critical of the monitoring of Mrs A’s condition and found there was no care plan for the management of her diabetes.  Furthermore, there were failings in pressure ulcer management and also in falls prevention.  We also found failings in stoma care, noting there was no care plan or fluid balance monitoring.  Finally, we noted that there was little evidence of family involvement in care planning and limited records of communication.  We concluded that the nursing care was unreasonable and upheld the complaint.

Mr C also complained that there was a delay in diagnosing internal bleeding during the admission to Woodend Hospital.  We found that medical staff reviewed Mrs A’s condition reasonably during the admission and we did not identify an unreasonable delay in the diagnosis.  While we recognised that there were issues with the nursing observations, we did not consider that these impacted on the ability of medical staff to diagnose Mrs A’s condition.  We did not uphold this aspect of Mr C’s complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

We are asking the Board to improve the way they do things:

[1] Since the time of the complaint, the following standards were introduced: Prevention and Management of Pressure Ulcers Standards. Healthcare Improvement Scotland (September 2016)

We are asking The Board to improve their complaints handling:

Feedback

Response to SPSO investigation:

Multiple enquiries were needed in order to obtain the records required by SPSO to carry out a full and detailed investigation.  This led to increased work and lengthened the investigation time.  I strongly encourage the Board to review the way evidence and responses are provided to SPSO.  The Board should ensure that all the relevant records are provided to SPSO at the first request.  Where additional enquiries are made by SPSO, the Board should provide the specific information requested and not duplicates of records already provided.

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.

Overview
The complainant (Miss C) had difficulties with recurrent ear infections due to a perforated right eardrum. In November 2010, she underwent a myringoplasty in order to treat this. Miss C experienced significant problems following the procedure, including balance problems, sickness and significant hearing loss in her right ear. In January 2011 she underwent a hearing test which confirmed the hearing loss, with limited options for treating this. Miss C complained to Tayside NHS Board (the Board) in January and March 2011 about the treatment she received including the treatment following the myringoplasty, but did not receive a final response until June 2012.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:

• (a) failed to carry out appropriate surgery and follow-up treatment following the myringoplasty on 5 November 2010 (not upheld);
• (b) failed to explain that the risks of surgery could result in hearing loss or balance problems (not upheld); and
• (c) failed to respond to Miss C's complaints in accordance with the NHS complaints procedure (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) offer Miss C an appointment with a senior otologist to discuss possible surgical options;
• (ii) provide evidence that staff on Ward 26 are aware of the procedure that should be followed when patients report post-operative problems;
• (iii) amend their Informed Consent Policy to ensure that patients who sign a consent form prior to treatment are given the option of receiving a copy;
• (iv) remind the medical staff involved in this complaint of the need to confirm consent as per the Informed Consent Policy;
• (v) conduct an audit of their internal complaints handling process to ensure that all complaints received are properly handled as per the Board's complaints procedure; and
• (vi) give a full and sincere apology to Miss C for the outcome of the myringoplasty, and for all the failings identified within this report.

Overview
The complainant (Mrs C) complained about the care and treatment provided to her husband (Mr C) following his admission to the Royal Alexandra Vale of Leven Hospital (the Hospital). Mr C was 90 years old and was admitted because he was suffering pains in his legs; prior to his hospital admission he was living independently with no other immediate health concerns. Mr C developed pneumonia in hospital and while being treated for this developed diarrhoea, kidney failure, a pressure ulcer and severe oral thrush. Mr C subsequently died. Mrs C felt the Hospital staff's lack of timely action had contributed to Mr C's death.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) staff did not diagnose the cause of pain in Mr C's legs (not upheld);
• (b) staff did not reasonably respond to Mr C's dehydration (upheld);
• (c) there was an unreasonable delay in carrying out an x-ray or scan following the diagnosis of a chest infection on 25 March 2012 (not upheld);
• (d) staff did not reasonably respond to Mr C's complaints of pain in his back on 1 April 2012 (not upheld); and
• (e) staff did not reasonably respond to the development of thrush in Mr C's mouth (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff at the Hospital of the need to communicate with patients and their relatives and carers to ensure they are kept fully informed about their care and treatment, and of the importance of a proactive approach in this regard;
• (ii) conduct an audit to ensure the timely assessment of all acute admissions by consultant medical staff;
• (iii) review the implementation of the fluid balance chart policy, with an emphasis on the identification of the appropriate point for staff to escalate concerns to clinical staff;
• (iv) ensure junior medical staff at the Hospital receive full training on the management of elderly and acutely ill patients with the aim of preventing kidney failure;
• (v) conduct a significant incident review with regards to the period of care from 27 March to 3 April 2012;
• (vi) issue a reminder to all medical staff at the Hospital to ensure that nursing staff are given timely notice of changes to patients' medication;
• (vii) advise staff at the Hospital that, where possible, patients and their families and carers must be able to discuss care and treatment with a named point of contact within the medical team; and
• (viii) give a formal apology to Mrs C for the shortcomings identified in this report and for the distress she has suffered.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) together with other members of her family raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) concerning the care and treatment their mother (Mrs A) received while a patient in the Victoria Infirmary, Glasgow between September and November 2010. Mrs A died in hospital on 13 November 2010.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the care and treatment provided to Mrs A, including the management of her pressure ulcer and the use of a Certificate of Incapacity, was inadequate (upheld);
• (b) the implementation and application of the Liverpool Care Pathway (LCP) was inadequate (not upheld); and
• (c) communication between board staff and Mrs A's family was unreasonably poor, in particular a meeting with Mrs A's Consultant on 26 October 2010, and a telephone conversation between Mrs A's son and a medical registrar on 1 October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence that the Board's current policies and procedures regarding the prevention, management, monitoring, education and training of pressure ulcers is in line with national guidance and best practice;
• (ii) take steps to put in place an action plan to address the shortcomings identified in this report in relation to pressure ulcer management and share this action plan with both the Ombudsman and Mrs C;
• (iii) review how in-patient units communicate with each other about the decision making capacity of patients requiring procedures as in-patients, to ensure that a patient who is being managed under the terms of the Adults With Incapacity (Scotland) Act 2000, is known to be so by any other team undertaking a procedure that would normally require written consent;
• (iv) consider whether the use of treatment plans (recommended for patients with complex care needs) might support the effective use and validity of Certificates of Incapacity in terms of Section 47 of the Adults With Incapacity (Scotland) Act 2000;
• (v) review how clinicians document the fact that capacity may be lacking for one specific intervention but present for other investigations and treatments if they believe this to be the case;
• (vi) ensure that family and carers are appropriately involved and informed of the consideration of use of the Adults With Incapacity legislation in the care of a patient and to document this clearly on the Certificate of Incapacity;
• (vii) apologise to Mrs C and other members of the family for the failings identified in complaint (a);
• (viii) with reference to our adviser's comments under paragraph 84 of this report, consider auditing the precise location of death of their in-patients and whether any system of prioritisation for single rooms across units might minimise this;
• (ix) seek to ensure that any discussion that a member of staff has with a patient's family is recorded in the patient's medical records; and
• (x) apologise to Mrs C and other members of the family for the failings identified in complaint (c).