Decision Report 201404639

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received during an admission to the Western General Hospital. Mrs C had advanced lung cancer and her admission was arranged when it was identified that her condition was deteriorating despite treatment. She was discharged home after two weeks with a palliative care package but died in another hospital five days later. Mr C complained about the standard of nursing and physiotherapy care provided to Mrs C during her two-week admission. He also complained about the standard of communication between staff and him and his wife.

We took independent advice from a nursing adviser. The adviser identified various deficiencies in the standard of record-keeping. For instance, pain charts and records of care rounds were not fully completed. However, we were advised that, overall, there were no serious flaws or omissions in the nursing care provided. We did not, therefore, uphold this complaint but we made a recommendation regarding record-keeping. We were also advised that the level of input from physiotherapists was reasonable and we did not uphold this complaint.

We upheld the complaint about communication. The board had already acknowledged that their communication with Mr and Mrs C could have been much better. In particular, they accepted that there was a lack of continuity and consistency amongst medical staff. They also apologised for the lack of suitable private rooms in the hospital for having confidential discussions with patients and their families. We did not consider that the remedial action planned by the board would address all of the identified communication failings, and we asked them to develop a more robust action plan to tackle the issues with medical continuity and consistency.

Recommendations

We recommended that the board:

• reflect on the failings identified, alongside relevant Nursing and Midwifery Council guidance, and inform us of the steps they will take to improve record-keeping;
• develop a robust action plan to address the acknowledged failings surrounding continuity and consistency amongst staff in the medical oncology (cancer) team; and
• apologise to Mr C for the failings identified.