An 81-year-old grandmother was left “screaming in agony” in a Fife hospital after staff failed to manage her pain properly before her death.
Stroke victim Jennifer Duff, from Markinch, had oozing wounds on her feet that were not appropriately treated during a stay at Queen Margaret Hospital in Dunfermline.
She also fell twice – once out of bed and once from a wheelchair – while unsupervised.
Jennifer, paralysed down one side and unable to speak as a result of her stroke, suffered a dislocated hip and shoulder while in ward seven.
And the former Fife Children’s Panel member later died at Victoria Hospital in Kirkcaldy.
Her devastated husband, Warner, 87, accused staff of neglect and told The Courier: “It’s heart-breaking.
“I’ve hardly slept since it happened. It goes through my mind every night.
“I wish I had said more when she was lying in that bed.”
Fife gran ‘in agony’ at hospital
The Scottish Public Services Ombudsman has upheld a series of complaints from Warner and his three daughters about Jennifer’s treatment.
However, they dismissed the claim hospital staff failed to notice the dislocations, saying these were unlikely to have been caused by the falls.
And while NHS Fife has apologised for the failings, the ombudsman was highly critical of the length of time they took to respond, both to them and to Jennifer’s family.
The case has only recently been resolved, almost three years after her death in August 2021.
Warner, who was married to Jennifer for 65 years. said: “When she was in Dunfermline, she screamed and screamed.
“She was in agony and they said there was nothing.
“Afterwards, we were fobbed off as they delayed and delayed.
“By the time we got it to the ombudsman it was a year-and-a-half on.”
Three complaints upheld including ‘unreasonable’ pain management
The ombudsman upheld three complaints:
- NHS Fife failed to manage Jennifer’s wounds appropriately
- The health board failed to manage her pain appropriately
- NHS Fife failed to properly respond to her falls
In her conclusion, she said: “A wound chart should have been completed for every wound. This did not happen.
“Dressings for her wounds were not appropriate.”
We recognise that the care we provided in this instance fell well below the standards that our patients should expect.” NHS Fife spokesperson.
Regarding Jennifer’s falls, the ombudsman said the board’s guidance is appropriate but only one of the two falls was documented.
The nursing care plan also did not advise that Jennifer needed supervision while sitting.
And the ombudsman added: “The board’s management of Jennifer’s pain was unreasonable.”
Staff have since completed online modules regarding wound care and pain management.
NHS Fife condolences and apology
In a letter to Warner Duff, NHS Fife chief executive Carol Potter expressed her condolences.
And she said: “I would like to apologise for the failings identified.”
Ms Potter said she accepted the ombudsman’s findings in relation to Jennifer’s wounds and falls.
She added: “We agree that an earlier and more regular review of her pain management should have taken place.
“I am sorry this did not happen and I apologise for any additional distress this caused.”
An NHS Fife spokesperson told The Courier: “We recognise that the care we provided in this instance fell well below the standards that our patients should expect.
“We have implemented the ombudsman’s findings in full.”
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