Decision Report 201201581

Summary

Mrs C complained about the care given to her late husband (Mr C) while he was in hospital. She said that he was moved three times but only on the last occasion was it suitable for his condition. She alleged that he was not comfortable or properly looked after and that his clinical care was poor. In particular, she said that he endured terrible pain when his chest drains were being replaced. Overall, Mrs C believed that the lack of proper care hastened Mr C's death. She further complained that she was not kept informed by staff about his condition.

In investigating this complaint, we obtained independent advice from medical and nursing advisers. We also took into account all the information provided by Mrs C and by the board (including the relevant correspondence and clinical records). The board had said that the clinical care and treatment given to Mr C were appropriate. However, our medical adviser said that Mr C should have been referred earlier to a thoracic surgeon and should not have undergone four attempts to insert chest drains, particularly without appropriate sedation. There were also failings in Mr C's nursing care, in that his dignity and privacy were not always protected. We, therefore, upheld Mrs C's complaints about her husband's care and treatment, although we did not uphold the complaint that she was not kept informed, as the evidence showed that good attempts were made to let her know what was happening.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for the shortcomings in the clinical care given to her husband;
• train doctors, as insertion care appears to be less than adequate, to ensure that drains are properly inserted and secured properly;
• review their protocol for Intercostal Chest Drain to ensure that it is sufficiently comprehensive and includes how to deal with recurrent pneumothoraces;
• make a formal apology to Mrs C for failings in the nursing care given to her husband; and
• provide the Ombudsman with evidence confirming that systems are in place (and regularly monitored) to address the failures identified.