The SPSO investigation also found the local health body had failed to administer the patient’s prescribed medication while he was being treated at Crosshouse Hospital in May 2010. Two other complaints – that staff had failed to recognise and address pain, and that they had not implemented the ‘Liverpool Care Pathway’ – were not upheld by the Ombudsman.
The patient, identified in the SPSO report as Mr A, was admitted to Crosshouse Hospital on May 21 2010, where he died two days later. The complainer, the patient’s wife, was referred to in paperwork as Mrs C.
As a result of its findings against NHS Ayrshire & Arran, the Ombudsman has recommended the local health board should:
(i) ensure that measures are taken to feedback the learning from all aspects of this event to the medical team involved with Mr A's care, to understand the importance of avoiding similar situations recurring;
(ii) review the process of pain scoring, its frequency and recording in this case and feedback the learning to nursing staff;
(iii) complete a review of the LCP within the unit and feedback the learning to all medical and nursing staff within the unit;
(iv) complete a full review of their medical staff cover for the night of 22 to 23 May 2010 to ensure such situations do not recur;
(v) provide an update of their review on the use of pager numbers;
(vi) apologise to Mrs C for the failures identified in this report.
In a statement, NHS Ayrshire & Arran indicated it “accepted the recommendations and will act on them accordingly”.