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Case ref:201806470
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Date:November 2019
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Body:Borders NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:continuing care
Summary
Mrs C complained about the care and treatment provided to her father (Mr A) at Borders General Hospital. Mr A had a long history of health problems including arthritis (a disease causing painfulinflammation and stiffness of the joints) and chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and he was admitted to hospital due to the severity of his tremors. Mr A had been taking regular doses of dihydrocodeine (DHC, an opioid painkiller) for several years for his arthritic pain. When he was admitted to hospital, Mr A's DHC was stopped and he suffered withdrawal symptoms. Mrs C complained that Mr A's medication was stopped for no reason. The board explained that there was no signature on the drug chart so they could not identify who stopped the medication and why but they had taken steps to address this failing.
We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the decision to stop the DHC was likely an error and we were satisfied the board had taken the appropriate steps to remind all junior doctors of the importance of documenting their decisions in the clinical notes. We upheld the complaint on the basis that it could not be identified why the medication was stopped and made a further recommendation in relation to complaint handling.
Mrs C also complained that Mr A was discharged from hospital when he was still very ill and that there was little consultation with the family and consideration of how they would manage at home. The board confirmed that Mr A was clinically well enough to be discharged home and that they delayed the discharge appropriately when Mr A's wife expressed concerns about how she would cope at home. We found that Mr A was medically fit for discharge and the process was appropriately managed. We did not uphold the complaint.
Recommendations
In relation to complaints handling, we recommended:
- Reasonable steps should be taken in future to identify relevant parties involved in complaint issues, to allow the issues to be thoroughly investigated, responded to in specific terms, and focussed learning to take place. This should be highlighted to all complaints handling staff.