Source · SPSO (Scottish Public Services Ombudsman)

Grampian NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201507637 Sector Health Category clinical treatment / diagnosis Decided 01 January 2017

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Full decision

Summary

Mr A had lung cancer and was receiving end of life care at home. Mr A's wife (Mrs C) complained to us about the care he received from district nursing staff, about the standard of communication, and about the board's response to her complaints.

Mrs C was concerned about a dose of medication given to Mr A by the nurses and about record-keeping. We took independent advice from a nursing adviser and a medical adviser. They found that there was no evidence that the standard of record-keeping affected the management of Mr A's symptoms. They also found no error in the prescription or administration of the medicine. We did not uphold these aspects of Mrs C's complaint.

Mrs C also complained about a decision to move Mr A in bed. She said that this caused him pain and was concerned that a bathroom towel was used. We found that moving Mr A in bed was a good way of assessing pain control and that both the decision to move Mr A and the way he was moved were reasonable.

Mrs C complained that she had not received a good standard of communication from the nurses. The nursing adviser said that Mrs C had not been offered support and there was no evidence that staff had listened to Mrs C's concerns. However, given the available evidence, it was not possible to reach a judgement on other aspects of Mrs C's complaint about communication.

Mrs C also said that the board failed to respond reasonably to her complaints and that their response was accusatory. We found that while the board's response addressed every clinical issue, there was no evidence of compassion or empathy. We therefore upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board: bring the failings in complaints handling to the attention of relevant staff and review their processes to ensure sensitive and appropriate responses to complaints; and apologise for the failings this investigation identified.

Related reading

View Decision Report 201507637 as a PDF (12.83 KB) Updated: March 13, 2018

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