NHS Fife has apologised to a grieving family over a catalogue of failings which blighted an elderly patient’s final days.
The 83-year-old woman’s family members were not even able say their final farewell to her before she died at Queen Margaret Hospital in Dunfermline.
Her upset daughter raised a number of concerns over the care and treatment of her late mother identified only as Mrs A with the ombudsman.
He agreed with the majority of the complaints in one case describing the failings as ”significant” and has made a series of recommendations which the health authority must implement to improve standards of care.
Mrs A was referred to the hospital by her GP to address fluid retention, assess kidney function and improve her mobility. When she was admitted, on April 12 2010, she was suffering from cardiorespiratory heart and breathing symptoms.
However, she contracted the winter vomiting bug that had broken out in the hospital, her breathing deteriorated and she died on May 5, three weeks after being admitted.
Her daughter made nine complaints, relating to the clinical treatment, nursing care, communication, record keeping and the way the health authority handled complaints, of which seven were upheld.
He did not uphold two further complaints: that staff had failed to ensure pills administered to Mrs A when she was in a semi-conscious state did not remain in her mouth for six hours and that there was a disagreement about the cause of death after a death certificate was issued and registered.
One of the ombudsman’s clinical advisers, while agreeing a new or prolonged course of antibiotics may not have any effect on the outcome, said the failure to consider the need to give further medication had been ”particularly concerning”.
And the ombudsman’s nursing adviser said that while it was difficult to assess the appropriate time to call a family when a patient’s health deteriorated, she found the communication with Mrs A’s family to be ”minimal”.
”She said that even in Mrs A’s final hours, she could find little evidence in the records to indicate that death was expected. She said that Mrs A’s family was not afforded important time to say their goodbyes to her,” the report stated.
The ombudsman also upheld the complaint that the board failed to ensure an incident form was completed and investigate properly a serious complaint against a staff member, after Mrs C claimed staff were ”unable to comprehend” what Mrs A’s mobility problems meant and how she should be moved.
Mrs C claimed that a staff member shouted at her mother and threw her legs back on the bed, resulting in damage to her skin which needed a dressing.
As a result, the ombudsman made eight recommendations.
These include reviewing the means by which the clinical judgments of Hospital At Night staff who see patients independently are monitored, conducting a review of the handover of information from team to team to see how it could be strengthened, drawing up and implementing an action plan to address failings in nursing care and ensuring that serious complaints are appropriately recorded and investigated.
The board was also asked about measures to ensure cause of death on certificates were accurate and ensuring clinical records were thoroughly reviewed.
NHS Fife chief executive George Brechin said: ”I wrote last week to the family to apologise for the failings identified in this report. On behalf of NHS Fife I would like to take this opportunity publicly to offer our sincere condolences.
”We accept the recommendations contained in the ombudsman’s report and have already implemented measures to address the issues raised, with working practice reviewed, and lessons learnt.
”We are keen to work with the family to provide assurances around our ongoing work if they would find that helpful.”