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Case ref:201507758
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Date:June 2016
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:admission / discharge / transfer procedures
Summary
Mrs C complained about the care and treatment provided to her late mother (Mrs A). Mrs C raised concerns that hospital staff at Dr Gray's Hospital unreasonably arranged to transfer Mrs A to Turner Memorial Hospital. Prior to the transfer, Mrs C had been treated in Dr Gray's Hospital for her existing chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). Mrs C said Mrs A had suffered diarrhoea on the day of the transfer and looked unwell.
The board said Mrs A's transfer had been reasonable. They said there was no evidence of diarrhoea prior to transfer, and Mrs A had been appropriately transferred.
After receiving independent advice from a geriatrician, we upheld Mrs C's complaints. We found that staff had unreasonably transferred Mrs A. In particular, we considered that Mrs A's condition was unstable, and her transfer was not subject to an appropriate level of consideration. We also considered that the board did not comply with the 'Can I help you?' guidance in answering Mrs C's complaint. We made a number of recommendations to address these concerns.
Recommendations
We recommended that the board:
- apologise to the family for the failings identified;
- confirm that the staff responsible will discuss this issue as part of their annual appraisal;
- remind staff of the importance of adequate record-keeping; and
- remind relevant staff of the complaints handling requirements under the 'Can I help you?' guidance.