Health Service Commissioner : Second report for Session 1981-82 : Selected investigations completed October 1981-March 1982.

  • Great Britain. Health Services Commissioner.
Date:
1982
Catalogue details

Licence: Open Government Licence

Credit: Health Service Commissioner : Second report for Session 1981-82 : Selected investigations completed October 1981-March 1982. Source: Wellcome Collection.

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    7. The A and E consultant (the surgeon) told the AHA that it had been the opinion of the A and E doctor that the patient required admission to a medical ward but he pointed out that the decision about admission under the care of that speciality was the responsibility of the SHO. 8. The staff nurse who, according to the hospital’s records had been primarily concerned with the patient in the A and E department and who had contacted the CNS told my officer that she could not remember her or the events complained of. However she said that she would have contacted the CNS on the instructions of the SHO and that she would have tried to keep relatives informed of the arrangements which were being made. She doubted if she would have given the impression that a social worker could be available immediately at a patient’s home as she knew this to be impracticable. I have seen that the staff nurse noted in the records that at 14.50 CNS had been contacted regarding the SHO’s instruction and that the DN would be contacted by CNS. 9. The CNS nursing officer (the NO) told my officer that the message from the staff nurse about the patient had been recorded by a clerk and I have seen that the entry includes the following note: “Being dis. pm 31.12.80. [SHO] writing to [FP] to ask for increased Social Services’, and it is further noted that the message had been passed to the DN. The NO said that the entry showed that no degree of urgency had been indicated when the message was given. She said that the DN was contacted after she had completed her afternoon rounds at 5 pm and had confirmed that she would visit the patient the following morning. The NO said that had a visit during the evening of 31 December been requested, this would have been arranged. 10. I have seen that in his report to the AHA about the complaint the physician, after describing the events of 31 December and 1 January, said ‘It is most unfortunate that the patient died after admission to hospital. It is difficult to answer the question as to whether she was wrongly discharged the day before because I did not see her. The physician wrote a further report after he had seen the complainant and her mother on 27 May. He said that their main criticism had been that the urgency of the matter should have been stressed to the district nursing and social services. The physician said that, in retrospect, it would clearly have prevented much anxiety and distress had the patient been admitted on her first attendance but that there had been no clear medical reasons for her admission. He had pointed out that although district nursing, social services and the FP had been notified perhaps they had not been told with sufficient urgency that they should visit the patient promptly. 11. The assistant divisional director of the SSD told my officer that they had no record of any message from the hospital asking for extra help for the patient, neither was there any record of the social workers at the hospital being asked. He said that SSD had been approached by the complainant’s mother and as a consequence of that call they had arranged extra help.
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