Decision Report 201508370

Summary

Mrs C complained about the care and treatment provided to her father (Mr A), who had been admitted to Southern General Hospital for surgery for a fractured hip. Mr A was initially found not be to fit for anaesthesia because of a lung condition and as he had pneumonia. However, he improved with treatment and underwent hip surgery. Mr A later dislocated his hip and developed further deterioration in his lung function and an infection. Mr A died in hospital.

Mrs C complained there had been a failure to provide Mr A with appropriate clinical treatment once it was found his condition had deteriorated, and that pain relief had not been put in place appropriately. She also complained there had been a failure to communicate adequately with the family about Mr A's clinical condition and prognosis and to provide him with an appropriate standard of nursing care.

We obtained independent advice from a medical adviser and a nursing adviser.

The advice we received from the medical adviser was that the clinical treatment Mr A had received was reasonable and that the pain relief given by the palliative care team was reasonable. However, they considered that control of Mr A's pain should have been managed better and sooner. We therefore upheld this aspect of Mrs C's complaint.

We also found that the level of communication with Mr A's family about his condition and prognosis was unsatisfactory. Whilst the advice we received was that communication by the nursing staff was reasonable, there were shortcomings in the medical staff's communication with the family, in particular a failure to convey effectively to the family that Mr A was dying. Given this, we upheld this aspect of Mrs C's complaint.

The nursing adviser considered that overall the nursing care provided to Mr A was reasonable and so in this regard we did not uphold Mrs C's complaint.

Recommendations

We recommended that the board:

• issue an apology to Mrs C for the failings identified in Mr A's pain management;
• ensure the comments of the medical adviser regarding the management of Mr A's pain control are brought to the attention of relevant staff;
• issue an apology for the failings identified with regard to communication with Mr A's family; and
• ensure the comments of the medical adviser are fed back to the relevant medical staff concerning communication and that they have been provided with adequate training in communication skills, especially in communicating news of a patient's prognosis to their family.