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Case ref:201405265
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Date:June 2016
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Body:Highland 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
Ms C, who is an advice worker, complained on behalf of Mrs A about the care and treatment she received at Raigmore Hospital. In particular, Mrs A said that the hospital failed to communicate adequately with her and her family during her admission. She also said that the hospital failed to provide an appropriate standard of nursing care or appropriate medical treatment.
We took independent advice from a nursing adviser and a medical adviser who is a hospital consultant. We found that the level of communication with Mrs A and her family was reasonable, as was the level of communication between medical staff. However, our investigation showed that the board failed to provide Mrs A with an appropriate standard of nursing care. We were mindful that the board had accepted there were failures in relation to nursing care and had taken action to address these matters.
We found that the medical care and treatment Mrs A received in the hospital was reasonable.
Recommendations
We recommended that the board:
- consider the nursing adviser's comments about the overall standard of record-keeping and provide details about when the improvements to nursing documentation are to be implemented and evaluated;
- provide an action plan to address the failures in relation to nursing assessments and pain management identified in this case;
- consider the medical adviser's suggestion about the development of a care plan for Mrs A and report back to us on any action taken; and
- remind relevant staff of the need to label each page within medical records with the correct patient identification details.