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Year: 2021
Date: 18 August, 2021
Offence Group: healthcare-related offences
Offence Type: care quality violation
Violation Description: Mrs B complained about information an NHS Trust provided to the Council's commissioned care home provider when her late father was discharged from hospital in December 2019. She complains a Surgery prescribed antibiotics but failed to send the prescription to the pharmacy. She also said the Home delayed in following up on the medication her father needed, and this contributed to his untimely death. We found the Trust at fault for poor record keeping when it dealt with the discharge, but it improved. Faults in the way the Surgery made an electronic request for medication and the Home's failure to take follow up action caused delay in the medication being received. The Surgery and the Home also missed an opportunity to report the incident to the Council so it could consider its safeguarding procedures. The authorities have agreed to our recommendations and the Council will monitor the Home to ensure it improves the way it records discharge information and it will provide safeguarding training if necessary. The Surgery will remind its staff of the importance of reporting safeguarding concerns to the Council when dealing with incidents relating to patient safety. The Home and the Surgery will apologise to Mrs B for the missed opportunity which contributed to doubt she has about the events which occurred.
Agency: Local Government and Social Care Ombudsman
Source of Data: (click here)