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Case ref:201306193
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Date:September 2014
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Body:Borders NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:communication / staff attitude / dignity / confidentiality
Summary
Mrs C told us that her late mother (Mrs A) did not get the care she deserved during the last few hours of her life at Borders General Hospital. She said that at other times the standard of care provided during her mother's stay in hospital had been good or excellent. Mrs C and other family members were aware that Mrs A was in the final few days of her life, and had stayed with her throughout the night. She said that Mrs A suffered unnecessarily because staff failed to check or assess her condition despite family members reporting her distress to them.
The board told us that Mrs A was assessed every time family members asked staff for help, although they also noted that drugs that might have provided some relief for Mrs A could have been given earlier. We found, however, that Mrs A's medical records did not contain the necessary entries to support the statement about assessment, and that there were some gaps in these records. Based on the information available we could not, therefore, conclude that they properly assessed Mrs A's needs, and we upheld the complaint.
Recommendations
We recommended that the board:
- provide us with an update on the service manager for medicine's review of this complaint and any action plan arising from this;
- undertake a further review of this complaint in the light of our findings and provide us with an action plan arising from this;
- apologise that there was no assessment at an earlier point of whether pain and symptom relief should be provided; and
- provide us with evidence of their current plan for terminal and end of life care and of the staff training undertaken to support this.