 | Author(s) | | | Abraham A. Health Service Ombudsman |
| Publication | | | Professional Nurse |
| Reference | | | 19:6 |
| Publication Date | | | 2003 |
|  | This paper looks at complaints published following investigations; I am looking at all three although case 3 is cancer related.
All practitioners are encouraged to look at their own practice. I am a firm believer that reflection on our practice improves the care we give.
We regularly talk both in clinical and academic fields about the value of reflection; these cases show how this reflection can hopefully make us look on past experiences and learn from them.
Case one looks at informed consent for a patient who received surgery (twice) despite the fact the patient lacked capacity to give consent (recorded in nursing notes but not in medical notes); the next of kin (son) complained he had not been informed in this process.
After the review the ombudsman reminded the trust of the importance of information giving to families and caregivers. The trust agreed to audit the consent procedure in patients who lack the capacity to consent to treatment.
Case two looks at nursing observations and the complaint procedure.
The case looks at a complication of pregnancy, which resulted in persistent headache, and loss of left side movement, initial diagnosis was migraine. A revised diagnosis showed a sagittal sinus thrombosis, five days later whilst admitted to the neurological center, the mother suffered an unwitnessed cardiac arrest and was transferred to the intensive care unit. A complaint was made by her partner about the care received, which took 10 month before a response was made. The partner was\dissatisfied and requested an independent review.
The ombudsman found problems with recordings of observations, especially on the evening of the cardiac arrest and the reporting of findings of such to the medical staff.
The response to the complaint was found unsatisfactory. The ombudsman recommended that the trust review the care plan of observations documentation, increase nurse education and improve record keeping.
Case three looks at nursing care and communication with carers.
A patient was admitted to a surgical ward with end stage cancer on the understanding of a transfer to a palliative care bed as soon as possible. Soon after admission the patient experienced deterioration in condition presenting with symptom control problems of nausea and vomiting and skin ulceration and exudation of her legs. The patient did not wish to be nursed in bed and went on to develop pressure sores.
The patients daughter complained that her mother was neglected by the nursing staff and that she was unattended for long periods resulting in her pressure areas being neglected and exudates was allowed to collect in pools on the floor, also communication with the family was poor.
Further complaints were made about decisions to resuscitate and medication problems.
The ombudsman found that documentation particularly around information to the family was poor and that care although not negligent was concerning, especially around palliative care, communication and the involvement of the multidisciplinary team.
Improvements were recommended around documentation, care planning, communication and involvement of the multidisciplinary team.
This paper highlights the issues, which are familiar to us all in practice, which the nursing and midwifery council advocate in their code of practice.
Comment by: Tracey Burgoyne, Lecturer Practitioner Cancer Care, University of Central England Birmingham, 2004.
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