Overview
The complainant, Mr C, complained that his late mother (Mrs A)'s fluid retention had not been treated correctly while she was in Wishaw General Hospital. He was concerned, in particular, about a failure to recommence diurectic medication. He believed that this led to congestion on Mrs A's lungs which he felt was the cause of her death. Mr C was unhappy that the death certificate said the cause of Mrs A's death was Alzheimer's disease.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Mrs A's fluid retention was not treated correctly (upheld); and
- (b) Mrs A's death certificate was completed incorrectly (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) pass a copy of this report to the Clinical Nurse Specialist who audited the ward in 2007 to decide whether it should be reflected in the action plan;
- (ii) create a structured programme of review of medical records;
- (iii) share this report with all clinical staff involved in Mrs A's care;
- (iv) ensure that, when clinical staff are asked to review meetings notes they are, where appropriate, reminded of the importance of checking the accuracy of clinical information provided;
- (v) apologise to Mrs A's family for the failures in her care;
- (vi) take steps to correct the error in Mrs A's death certificate or provide acceptable reasons why this cannot be done;
- (vii) consider whether death certification should be included in the continuing education of medical staff; and
- (viii) apologise to Mr C for the failure to respond appropriately to his concerns about the error in the death certificate.
The Board have accepted the recommendations and will act on them accordingly.