Summary
C complained about arterial surgery. The board accepted that there were issues related to the systems in place at the time for the sharing of information between board sites and communication, and apologised for this.
We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, the issues related to the sharing of information between board sites and communication meant that aspects of the care and treatment C received fell below the standard C could reasonably expect. We upheld C’s complaint.
Recommendations
What we said should change to put things right in future: That the board review their policies and practice regarding inter-hospital transfers, specifically around documentation accompanying patients and verbal ward-to-ward handovers and that the board feedback the findings of this investigation to the medical team involved with C to highlight the poor communication with C and their family whilst they were in hospital.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202202648 as a PDF (25.39 KB) Updated: January 24, 2024