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Case ref:201508078
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Date:July 2016
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Body:Ayrshire and Arran NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C was admitted to University Hospital Crosshouse with a suspected infection following shoulder surgery a few days earlier. He complained that he received poor care in relation to the infection that developed in his wound, which required treatment under three separate general anaesthetics. Mr C was dissatisfied with the nursing care in terms of the lack of access to a bathroom and a shower, as well as the way in which his medicines were administered. He also complained about the board's delay in responding to his complaint.
We took independent advice from medical and nursing advisers on the care and treatment Mr C received. We were critical of a lack of evidence showing that Mr C's wound had been examined by three different doctors who had reviewed him on the day of admission to hospital. We made a recommendation to address this failing. However, we considered the assessments and treatment carried out thereafter were reasonable. In terms of the nursing care, we found that there was good reason (because of infection control and the facilities in the high dependency unit) for Mr C not having specific access to a bathroom and shower.
We did not uphold Mr C's complaints about his medical and nursing care, although we did identify shortcomings in the prescribing of his medication and made two recommendations to the board about this. There was also an unreasonable delay of four months in the board responding to his complaint and we made a further recommendation to address the matter.
Recommendations
We recommended that the board:
- review their medicines reconciliation process to ensure that medication is prescribed and checked in a systematic manner;
- draw to the attention of the medical staff involved in Mr C's care the failure to review his heart rhythm to check whether he required to continue with the existing treatment or have any additional medication prescribed;
- review their handling of Mr C's complaint in order to identify ways in which they can ensure regular updates are given and keep any delays to a minimum; and
- share the adviser's comments with the three doctors involved in Mr C's care.