Overview
The complainant (Ms C) was concerned about the care and treatment provided to her father (Mr A) when he had attended at St John's Hospital (Hospital 1) following a fall at home. Mr A had been taken to Hospital 1 by ambulance on 1 November 2008 but had been discharged a short time later. Mr A was found some distance from his home in the early hours of 2 November 2008. On that occasion he was taken by ambulance to a hospital in another board area (Hospital 2). Despite requests, Hospital 2 was not provided with Mr A's notes from Hospital 1. Mr A died in Hospital 2 on 5 November 2008.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the decision to discharge Mr A was inappropriate (upheld); and
- (b) the complaints handling and information provided was inadequate (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake an audit of the action plan and provide him with details of the outcome;
- (ii) satisfy themselves that the transfer of records between hospitals and Board areas is being carried out quickly and efficiently;
- (iii) review their complaints procedure and related guidance to staff, in order to ensure that complainants are provided with a full response supported by staff statements and records;
- (iv) ensure, when investigating complaints, that documentation is kept of interviews and key actions;
- (v) apologise to Ms C and Ms D for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.