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Selected Investigations Completed December 2000March 2001 > Part I, Case no. E.1347/99-00
Complaint against: Warrington Hospital NHS Trust
Summary of case
On 20 October 1998, Mrs P’s father, Mr R, was admitted to Warrington Hospital after suffering a stroke. He was transferred to an acute stroke ward, ward B14. On 24 October, Mrs P visited her father and was told that his condition had deteriorated overnight and that he had been prescribed antibiotics. Mrs P visited again the next day and saw that her father had deteriorated further and was not receiving any medication. A nurse confirmed to Mrs P that her father was not receiving the antibiotics prescribed, as the pharmacy had closed. Mr R was eventually given antibiotics later that day. His condition continued to deteriorate and he died on 27 October.
Findings
The Ombudsman found that ward B14 was exceptionally busy at the time of Mr R’s stay and that it had changed from general rehabilitation to acute care without any staff increase. The outcome of this was that three nurses, in succession, did not give Mr R his antibiotics and failed to follow the Trust’s drugs policy. However, despite the demands on staff, it was noted that Mr R did receive nursing care in accordance with his care plan. It was unclear what effect the delay in administering the antibiotics would have had on Mr R, but the Ombudsman found that if a course of treatment is prescribed by medical staff, it would be reasonable to consider it necessary for the patient to receive that treatment. The Ombudsman upheld the complaint. He criticised managers of nursing staff who should have been more aware of the consequences to patient care of low staffing levels and such a skill mix.
Remedy
The Ombudsman recommended that a skill mix review of staffing levels be carried out on ward B14; that local and Trust-wide induction training should include awareness of Trust policy and procedures; and that staff working permanent night duty be provided with the opportunity to work day shifts in order to update themselves. The Trust agreed to implement the Ombudsman’s recommendations and apologised to Mrs P.
Full text of this investigation
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