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Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.1208/00-01
Complaint against Morecambe Bay Hospitals NHS Trust
Summary of Case
Mr U, who suffered from senile dementia, paranoid delusions and osteo-arthritis, and had recently been diagnosed with an abdominal aortic aneurysm (swelling of the main artery to the abdomen and the legs), was admitted to the Trust by his GP for respite care. The medical care in the ward was managed by GPs; the Trust provided the nursing care. The GP did not inform the nursing staff of the aneurysm; members of Mr U’s family brought this diagnosis to the attention of staff on the ward. Mr U’s bed was situated in a bay which could not be seen from the nursing station, and his call buzzer was not working. Mr U had two falls while in hospital. Two weeks after his admission, Mrs U visited her husband and noticed that his stomach was swollen to the point that he could not fasten his trousers; she brought this to the attention of the nursing staff. Mr U was also complaining of backache. After being returned to bed that night, after his second fall, Mr U died alone in the early hours of the morning; his death was later established to have resulted from the rupture of his aneurysm. His family complained about the Trust’s failure to act on the signs that Mr U was close to death by informing his wife, about the lack of a call buzzer by his bed, and about the failure of the nursing staff to manage his medication and dietary needs. Mr U’s son also complained that the Trust’s consideration of his complaint was protracted and inadequate.
Findings
Because the nursing records were very poor, and the nurses who cared for Mr U had not been involved in the attempted local resolution of his complaint, the Ombudsman was unable to answer many of the questions posed by Mr U’s family through her investigation. The Ombudsman’s nursing adviser noted that although appropriate care plans had been made for Mr U on his admission, there was no evidence of monitoring or review of those plans, of regular baseline observations being undertaken, or of certain medications being dispensed appropriately. She was also concerned at the isolated position of Mr U’s bed, and the lack of any means for him to attract the nurses’ attention. The Ombudsman found that the Trust had failed to offer a timely meeting with Mr U’s son to resolve his complaint, and had failed to involve the nursing staff in its investigation. She upheld both complaints.
Remedy
The Trust acknowledged that its standards of nursing documentation were poor, and the Ombudsman welcomed the commitment it demonstrated during the investigation to remedy this situation, using the Department of Health’s ‘Essence of Care’ document. The Ombudsman recommended that the Trust implement an audit programme to support its initiative. The Ombudsman welcomed the Trust’s plans to move and reorganise the ward where Mr U had stayed; she recommended that patients unable to summon help independently be nursed elsewhere until refurbishments were complete. She went on to recommend that the Trust offer meetings with staff to complainants early in the complaints process; involve relevant personnel at an early stage of a complaint; and take steps to provide more timely responses to complaints. The Trust agreed to implement these recommendations.
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